Some Patients Battle Illness or Injury – and Surprise Bills

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Source: Boston Globe

Cheryle Reidel knows a thing or two about surprise medical bills. There was the $6,000 for a cancer biopsy in 2012. Several years later, an anesthesiologist and a nurse anesthetist billed her $2,600 for another procedure.

This year, it happened again: Reidel underwent a colonoscopy at Norwood Hospital — which is fully covered by her insurance plan — only to discover that the anesthesiologist who worked there was not. The bill: $2,490.

What happened after Reidel, 64, received these unexpected medical charges illustrates one of the most frustrating and unpredictable aspects of the health care system: It was only after dozens of phone calls and numerous letters to insurance companies and the providers that she got these bills dismissed. Other patients have not been so lucky.

Reidel was one of more than 25 readers who wrote to the Globe after the newspaper published a story last month about out-of-network billing, expressing frustration with unexpected charges.

“The patient should not be on the hook for spending hours and hours digging through paperwork, printing out documents, and contacting the insurance company, contacting the anesthesiologists, contacting the hospital,’’ Reidel said. “That’s ridiculous. I work a full-time job.’’

Chloe Nasser’s parents have been relentlessly fighting such bills. Last summer, her doctor, who is affiliated with Brigham and Women’s Hospital, ordered routine blood work — at a lab in the same office. She was astonished to get a $701.89 bill a month later because the lab was not in her insurance network.

The family is also contesting a much larger out-of-network bill for a colonoscopy Nasser had at the Brigham, said her mother, Kathleen Wynn.

Surprise out-of-network medical bills occur when a hospital uses anesthesiologists, radiologists, ambulance companies, emergency medicine doctors, or other providers that are not covered by a patient’s insurance network. Often, providers do not inform patients in advance.

The practice is under growing scrutiny nationwide. A new analysis shows these charges, also called balance billing, may be more common in Massachusetts than previously believed.

A study by the nonprofit Health Care Cost Institute found that 15 percent of 9,041 in-network hospital admissions in Massachusetts in 2016 included an out-of-network bill from a professional who worked there — the 11th-highest rate in the country.

David Seltz, executive director of the Massachusetts Health Policy Commission, a watchdog group, cautioned that the study only examined medical claims from large national insurers. Massachusetts-based insurers tend to have more providers in their networks, so there is less chance for a patient to be hit with a surprise medical bill.

Still, the new information “reinforces the need and urgency for the [state] to take action to address this issue and help protect patients,’’ Seltz said.

The Globe reported in March that about 115 patients filed complaints about surprise medical bills in 2017 and 2018 with Massachusetts Attorney General Maura Healey’s office. Readers responded to the article quickly and passionately.

One theme was clear: Patients usually just paid bills that ran in the hundreds of dollars because they were either too busy or too sick to fight over relatively small amounts; however, others with large balances were relentless in challenging the charges. Many readers held hospitals responsible for using out-of-network doctors.

The Globe reviewed bills to verify readers’ complaints.

A few examples:

 Nancy Welsh took her diabetic daughter to Emerson Hospital’s emergency department last July because she wasn’t eating or drinking. Doctors started intravenous fluids and called Armstrong Ambulance Service to transfer her to Boston Children’s Hospital.

Several weeks later, the family received a bill for more than $3,000. Armstrong, it turns out, was not covered by their Aetna insurance plan. After eight phone calls, four e-mails, and a registered letter, Aetna reimbursed Welsh in February.

“A lot of people would have given up,’’ she said. “The more they stalled, the angrier I got.’’

But Welsh wondered why staff at the Concord hospital did not warn her in advance. Emerson spokeswoman Leah Lesser said there are so many different and ever-changing insurance companies and plans that it is often not possible to determine a patient’s coverage in an emergency.

“We encourage patients, before they need care, to learn what is covered by their insurance plans,’’ Lesser said in a statement.

 Jonathan Scott, 61, was diagnosed with advanced cancer in 2016. Scott’s oncologist and surgeon at Beth Israel Deaconess Medical Center were covered by his Tufts Health Plan network, as was the hospital, he said. Another surgeon — apparently not covered — was assigned to implant a tiny catheter above Scott’s heart through which he would get chemotherapy.

Weeks later, he received a bill for $1,198.

“I couldn’t eat or walk and I was having to deal with the insurance company,’’ Scott said. Tufts eventually agreed to waive the charges, he said.

Hospital spokeswoman Jennifer Kritz said she could not comment on Scott’s case because of patient privacy rules but said patients generally need prior approval from their insurance companies for procedures.

Patients have been receiving these unexpected bills for years. Doctors often blame insurers for the problem, saying the large national companies don’t pay enough for them to join their networks. Meanwhile, insurers argue that doctors prefer to remain out-of-network because that allows them to charge inflated rates, rather than accept a negotiated fee.

A number of states have passed laws regulating out-of-network billing. After failing to pass consumer projections last year, Massachusetts legislators plan to reconsider similar measures this year.

Hospital officials often say the problem is between insurers and doctors’ groups. State laws typically include a way for the two sides to reach fair payment rates. But Frederick Isasi, executive director of the nonprofit Families USA, said hospitals share the blame.

“They are selecting their providers,’’ said Isasi, who recently testified before Congress on the issue. “They have a responsibility to make sure they are in-network.’’

Reidel, a sales analyst for a medical supply company, agrees.

Her first two surprise bills involved care she received at Sturdy Memorial Hospital in Attleboro, which was in her insurance plan’s network, she said.

Amy Pfeffer, Sturdy’s chief financial officer, said the hospital strongly encourages all providers to join the same networks as the hospital but does not require it. Mandating it, she said, might force doctors to accept smaller payments from insurers that do not cover their costs.

“That would tie their hands,’’ she said.

After receiving the $2,490 bill from Ether Anesthesia of Massachusetts following her colonoscopy at Norwood Hospital last year, Reidel left a message for the hospital’s chief executive. Reidel said two weeks later, Norwood’s Chief Financial Officer Elizabeth Ganem told her the charges were resolved.

When asked why Norwood Hospital allows out-of-network anesthesiologists to work there, spokeswoman Lisa Tarabelli said in an e-mail that the “hospital is in the process of bringing the provider in-network.’’

Chloe Nasser’s family is unsure whether they will succeed in their battle over large out-of-network medical bills for medical care at Brigham and Women’s Hospital.

Ethan Slavin, a spokesman for Aetna, her insurer at the time, said many Aetna plans include the Brigham in their network. But not Nasser’s particular plan; her Brigham doctor was covered, but the hospital itself was not. And that is where her doctor sent some lab work and where he sent her for a colonoscopy. Wynn, Nasser’s mother, said no one mentioned this possibility.

The Brigham said it is improving its educational materials for patients to better explain the medical bills they might face. That information is expected to be ready in May.

Last Updated 08/18/2019

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