Article on balance billing

Twitch · Dec 26, 2008

http://www.businessweek.com/magazine/content/08_36/b4098040915634.htm

^ A bizarre article on how some hospitals/providers are billing patients directly for any remaining balance they think they should get paid beyond their contracted rate.

Tired · Dec 26, 2008

Twitch said:
http://www.businessweek.com/magazine/content/08_36/b4098040915634.htm

^ A bizarre article on how some hospitals/providers are billing patients directly for any remaining balance they think they should get paid beyond their contracted rate.

I'm a little suprised that the insurance carriers don't prohibit this as a terms of their payment contract. Medicare does.

niranjan162 · Dec 26, 2008

Tired said:
I'm a little suprised that the insurance carriers don't prohibit this as a terms of their payment contract. Medicare does.

y would insurance companies care, they're not being asked for the extra money.

Tired · Dec 26, 2008

niranjan162 said:
y would insurance companies care, they're not being asked for the extra money.

The same reason Medicare cares: when patients get a bill for monies that their plan won't pay, they don't complain to the hospital, they complain to their insurance carrier. More pressure to cover a larger cost-share is bad for business.

Imagine how much higher reimbursements would be if Medicare beneficiaries were beating down Congress' door because they were getting bills for the remainder of the actual cost.

ar2388 · Dec 26, 2008

ive totally had this happen to me.. thankfully i just sent them a copy of my insurance card and they left me alone

cpants · Dec 27, 2008

Time for doctors to walk away from all of this garbage. Patients should be billed directly. Let them fight with the the government and the insurance companies.

LeemerDO · Dec 27, 2008

I actually rotated through a Prime Healthcare hospital before as a med student. A couple actually. It's actually quite a shrewd way of medical billing. You see, these hospitals, if I understand, do not contract with any HMOs or Insurances for negotiated rates. You get seen at one of these hospitals, insurance has to foot whatever bill these hospitals see fit to send them. With no contract, the sky's the limit. So technically, it's within their right to do so. So I guess the next time anyone has an emergency and needs to go to a hospital, I guess be sure to go to one that your insurance has a contract with (as if that was possible while your heart muscle dies or your brain cells liquify).

Caveat Emptor, everyone!

docB · Dec 27, 2008

This is a horribly biased article against balance billing. The article makes some statements that are just plain wrong and makes some really frightening points. For example:

"It is inappropriate to put the patient in the middle of this." says Cindy Ehnes, director of the California Managed Health Care Dept.

It's inappropriate to involve the patient in paying for their own healthcare? Wow!

The majority of balance billing occurs when patients get care from providers not contracted with their healthplans. They get billed what ever they get billed. The healthplan, which has no pre-existing agreement with that provider, then pays some portion of the bill. They usually base that on what they would pay a contracted provider. The provider, saying "Hey, I never agreed to work for this." then bills the patient. This frequently happens with emergency care so it involved EPs and all the docs on call to the ED.

The point the article doesn't make is that if you outlaw balance billing (as CA and some other states have done) you make every doctor in the state an HMO doctor as they will be required to accept the lowest reimbursement that any healthplan pays their contracted doctors. Prohibitions against balance billing place all of the power in the hands of the insurance companies because they can then reducae payments to whatever they wish and they are assured that every doc, contracted or not, must accept it.

http://www.epmonthly.com/index.php?option=com_content&task=view&id=334&Itemid=15

http://www.calaaem.org/legislative.php

In this case ACEP and AAEM agree and that doesn't happen too often.

michaelrack · Dec 28, 2008

I am having trouble understanding this whole balance billing debate.

When I see a patient with insurance I am not in network with, I submit a bill to his insurance company. The insurance co then sends me an offer (in the form of a fax). I can either accept the insurance company's offer as payment in full (+ any applicable copays) or reject the offer. If accept the offer, I get paid that amount by the insurance co within a week or two- but can not "balance bill" the patient; I am limited to collecting the insurance co's standard copay from the patient. If I reject the offer, I can bill the patient my full usual customary fee, but will get nothing from the insurance co and have to rely on the patient's ability to pay.

Is this not how it works in California??

deleted87716 · Dec 28, 2008

michaelrack said:
When I see a patient with insurance I am not in network with, I submit a bill to his insurance company.

That's silly. You should just bill the patient directly, and let them worry about getting reimbursed through their insurance plan. I assume there's a reason you're not already in-network (like...poor reimbursement)?

LeemerDO · Dec 28, 2008

There's always the tried and true CASH UP FRONT and the office will then help the patient fill out an insurance reimbursement form so they can reclaim their money. Yes, it's not very practical for emergency medical care, but I'm sure it would work great for clinics.

Then if the patient gets pissed that the insurance will either not pay or pay a fraction of what's due back to them, just grin and say "How does it feel to be treated like a doctor? Welcome to MY WORLD!" :laugh:

michaelrack · Dec 28, 2008

Blue Dog said:
That's silly. You should just bill the patient directly, and let them worry about getting reimbursed through their insurance plan. I assume there's a reason you're not already in-network (like...poor reimbursement)?

1. I was a little bit sloppy in my post, many of the bills were submitted for sleep study interps rather than patient encounters. Many are from one sleep lab where I was specifically asked to read sleep studies of that insurer (the medical director of that sleep lab reads the other sleep studies, but refuses to accept the out of network rate from that one insurance co, which was hurting the business of that sleep lab)

2. The out of network rate that insurance company pays, at least for sleep studies, is bettern than the in-network rate for most other insurance companies.

3. It is very hard to get in-network with this company. For specialists, you have to be on staff at one of 2 Jackson MS hospitals. After finally getting that accomplished, I found out that the person who I was planning on listing as cross-coverage on my network application wasn't a member and I couldn't use him. I am trying to fix this situation. Also, it costs $1500 to join the network plus you have to kick back 1% of your reimbursement from the insurance company on a monthly basis. Even with all of that, it's considered to be the most desirable and best paying of MS insurance associations, and they control a lot of patients.

Zanegray · Jan 10, 2009

cpants said:
Time for doctors to walk away from all of this garbage. Patients should be billed directly. Let them fight with the the government and the insurance companies.

Amen.

If you give people something for free, they value it at nothing. Not that insurance is "free," but patients have become unaccustomed to paying nothing for care. Understandably, they don't value it, because they have no idea what it costs. It would be interesting to find out what percentage of insured patients know off hand how much money their employers contribute for their insurance.

docB · Nov 15, 2009

There is an article in this month's ACEP News that discusses the ramifications of the CA Supreme Court ruling earlier this year against balance billing. For some reason you have to be an ACEP member to see it but here's the summary:

Balance Billing Ban Triggers Lawsuits

It was January 2009 when the California Supreme Court prohibited emergency physicians from balance billing the several million patients covered under that state's HMOs and Blue Cross and Blue Shield PPOs. But now class action attorneys are moving in--both to file lawsuits against illegal balance billing that is still taking place and to have the state court's ruling applied retroactively.

And here's the link for anyone who might be an ACEP member.)

It notes that since the ban on balance billing the lawyers have started to circle both with the intent of suing on behalf of anyone who was billed after the ruling as well as trying to get the courts to apply the ruling retroactively. That means that if you were paid for services in the past you could be forced to give that money back.

Let me again point out that while Emergency Physicians are affected by this it also affects any physician who takes call for an Emergency Department. The prohibition on balance billing means that if you are obligated to care for a patient under EMTALA and that patient is with a plan that you do not contract with you are obligated to accept whatever base rate that plan deems "appropriate." If some HMO pays its contracted docs $100 to do a chole and you do an emergent chole on one of their patients you'll get $100 and you have no other recourse to be reimbursed.

I should also point out that the ideas about getting cash up front don't apply here as we're talking about EMTALA mandated care.

So be afraid. This type of legislation is becoming more and more popular and it's almost impossible to defeat it politically.

cpants · Nov 16, 2009

docB said:
There is an article in this month's ACEP News that discusses the ramifications of the CA Supreme Court ruling earlier this year against balance billing. For some reason you have to be an ACEP member to see it but here's the summary:

And here's the link for anyone who might be an ACEP member.)

It notes that since the ban on balance billing the lawyers have started to circle both with the intent of suing on behalf of anyone who was billed after the ruling as well as trying to get the courts to apply the ruling retroactively. That means that if you were paid for services in the past you could be forced to give that money back.

Let me again point out that while Emergency Physicians are affected by this it also affects any physician who takes call for an Emergency Department. The prohibition on balance billing means that if you are obligated to care for a patient under EMTALA and that patient is with a plan that you do not contract with you are obligated to accept whatever base rate that plan deems "appropriate." If some HMO pays its contracted docs $100 to do a chole and you do an emergent chole on one of their patients you'll get $100 and you have no other recourse to be reimbursed.

I should also point out that the ideas about getting cash up front don't apply here as we're talking about EMTALA mandated care.

So be afraid. This type of legislation is becoming more and more popular and it's almost impossible to defeat it politically.

Yes, but if you are not under contract with the insurer, you could still refuse any reimbursement from them and bill the patient in full, right?

docB · Nov 16, 2009

cpants said:
Yes, but if you are not under contract with the insurer, you could still refuse any reimbursement from them and bill the patient in full, right?

No.

From what I understand from the portions of my company that operate in CA that doesn't work because the insurers tell the patients that they will reimburse them (the patients) X amount and that is all they are obligated to pay of the bill. This is not even a viable option at this point (as the article alludes to) there are lawyers now suing on behalf of any insured patient who gets a bill for anything.

cpants · Nov 17, 2009

docB said:
No.

From what I understand from the portions of my company that operate in CA that doesn't work because the insurers tell the patients that they will reimburse them (the patients) X amount and that is all they are obligated to pay of the bill. This is not even a viable option at this point (as the article alludes to) there are lawyers now suing on behalf of any insured patient who gets a bill for anything.

I see what you're saying, and of course you might get sued, but in that case there are two separate transactions going on which have nothing to do with each other. Doctor bills patient X amount, insurance reimburses patient Y amount. I don't see why there is any obligation for the physician to accept Y as payment if he has no contract with the insurance company. He can simply continue to bill the patient for the outstanding balance and get a collections agency involved if necessary.

docB · Nov 17, 2009

cpants said:
I see what you're saying, and of course you might get sued, but in that case there are two separate transactions going on which have nothing to do with each other. Doctor bills patient X amount, insurance reimburses patient Y amount. I don't see why there is any obligation for the physician to accept Y as payment if he has no contract with the insurance company. He can simply continue to bill the patient for the outstanding balance and get a collections agency involved if necessary.

Because the Supreme Court of CA decided that's how it is.

cpants · Nov 17, 2009

docB said:
Because the Supreme Court of CA decided that's how it is.

Thats not what the summary you posted said. It said that once you accept payment from an insurance company you can't balance bill the patient. That doesn't mean that once you receive partial payment from a patient you can't balance bill the patient.

docB · Nov 17, 2009

cpants said:
Thats not what the summary you posted said. It said that once you accept payment from an insurance company you can't balance bill the patient. That doesn't mean that once you receive partial payment from a patient you can't balance bill the patient.

Ok. Here is what this means: per the California Supreme Court if you provide EMTALA mandated care to a patient and you are not contracted with their plan you must accept whatever payment their plan gives you and you are prohibited from billing them for the balance.

Other regulations bar you from demanding cash up front (EMTALA) or billing the patient directly as you suggest.

EmCare, EPMG, CEP, CalACEP and others have had TEAMS of very expensive lawyers working on this for years now. We fought it all the way to the state supreme court and lost. This is how it is. You will not be able to find a simple loophole to get around this.

yasinthomas · Dec 9, 2009

This article should be read by everyone as it gives you the correct information how it works......This problem is very silly and common..bill shoud be paid by patient and later on they can reimburse..

Dirt · Dec 11, 2009

docB said:
Ok. Here is what this means: per the California Supreme Court if you provide EMTALA mandated care to a patient and you are not contracted with their plan you must accept whatever payment their plan gives you and you are prohibited from billing them for the balance.

Other regulations bar you from demanding cash up front (EMTALA) or billing the patient directly as you suggest.

EmCare, EPMG, CEP, CalACEP and others have had TEAMS of very expensive lawyers working on this for years now. We fought it all the way to the state supreme court and lost. This is how it is. You will not be able to find a simple loophole to get around this.

Explain to me then why they can't just set reimbursements at $1 for a lap chole?

The patient's will get what they want, since according to this you cannot turn them down. The insurance company only has to pay a buck since that is the rate they decide, and there is no recourse. If things are as you say they are I see no reason why this is not plausible.

docB · Dec 12, 2009

Dirt said:
Explain to me then why they can't just set reimbursements at $1 for a lap chole?

They can. But they know that if they do they (the insurers) would be sued and they'd lose if they made it that obvious. What they do is they pay whatever their contracted rate is. And you can imagine that the contracted rate for an HMO is significantly less than the market mean in most places.

The legislature and the courts didn't do this to punish doctors. They did it in a misguided attempt to protect patients. For that reason they won't let the HMOs get away with paying nothing. The really egregious aspect of this is that when they pay their contracted rates they are forcing docs, who never got to negotiate these contracts, to accept the contract. If the HMO is able to get some doc or group of docs to sign on to some really lowball rate then everyone who is forced by EMTALA to see those patients will be paid that rate without any recourse.

Article on balance billing

Full Member

Fading away

Full Member

Fading away

rads resident

Member

4 FOX ACHE

Chronically painful

All In at the wrong time

deleted87716

4 FOX ACHE

All In at the wrong time

Full Member

Chronically painful

Member

Chronically painful

Member

Chronically painful

Member

Chronically painful

New Member

Full Member

Chronically painful

Similar threads