Who Gives A S**t About The Public Option, What About Balance Billing?

[TomCADem]

I really do think that the controvery about the Public Option is really obscuring some vital areas of reform that the public option by itselt is not going to address. For example, what about out of network costs?

This is a widespread, but ignored problem, that is being lost in the media caucophany regarding the public option, which somehow became the frickin third rail. The public option does not address out-of-network costs, and I would like to see some focus on this issue. The NY Times, to its credit, has run stories on this, but it is not as sexy as the public option is socialism debate. So, don't just be another media following lemming. If we get a public option, but the subject of out of network costs is not addressed, then we have left a huge loophole in the current and future insurance system.

http://www.mcclatchydc.com/congress/story/74099.html

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On the evening of March 1, 2008, Gary Diego was relaxing with his wife, Ellen, when she abruptly lost her hearing, began repeating herself, and seemed to be losing her grip.

Alarmed, Diego rushed her to his insurance company's in-network hospital, near his home in Truckee, Calif. Unable to handle what was determined to be bleeding in the brain, the hospital quickly transferred her to Renown Regional Medical Center in Reno, Nev., where she spent 17 days in intensive care. While recovering, she caught pneumonia and died.

A few weeks later, a still-grieving Diego learned from his insurer, Health Net, that he owed the Reno hospital more than $75,000. The reason? The hospital wasn't in his approved network.

Diego's story is an extreme example of what can happen in medical emergencies. Consumers who are careful to choose in-network doctors and hospitals for their routine medical care often can't choose where or how they are treated in an emergency. In a practice known as balance billing, insurers pay a portion of the out-of-network charges, and the balance owed to hospitals and doctors is dumped on patients.

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[Oregone]

1. "I really do think that the controvery about the Public Option is really obscuring some vital areas"

I gotta wonder if thats its purpose

[European Socialist]

2. Yup, this happened to me on a much smaller scale.

[FlaGranny]

3. The public option

does not HAVE networks - think Social Security. The network in Social Security is anywhere you happen to be and just about any doctor you want to see - even without referrals. The damned insurance companies would have to wise up very quickly on the network issue if there were a public option plan available. Public option solves many or most problems, but does not come close to single payer. Anyway, it's the only thing that would keep the ins companies honest if they want to stay in business.

[ProSense]

5. This is the media creating another distortion. n/t

[MH1]

8. But if I understand correctly, many (most?) of us will not be eligible for the Public Option

There's probably good stuff in the bill, but very little I've heard addressed in the current debate seems like it will change my every day experience of our health system. (I work for a large company and the only "choice" I get is between a high deductible, low premium plan or a high premium, POS plan, from the same insurer - Blue Cross- that was chosen by my company. Some free market there, huh.)

[Teaser]

4. As I've said before, reforming "fee-for-service"

is still my biggest concern. And no one is touching that, except maybe in Massachucetts.

[ProSense]

6. That issue is going to be addressed through competition,

caps and other cost controls. Remember private insurance has to compete effectively with the public option. If it can't over time it will begin to lose customers.

[WinkyDink]

7. "Over time", eh?

[ProSense]

9. No, the day after it's signed into law. n/t

[AwakeAtLast]

10. Get rid of the networks

Just changing things so that you can get care with any doctor anywhere would make a big difference in health care. They'll fight tooth and nail just to keep it.

Thanks for posting - good food for thought!

[RichGirl]

11. Well...maybe...but....

I pay for my own insurance. It is major medical, meaning I have a huge deductable and basically get nothing unless I have a catastrophic illness, then only get a percentage paid. It goes up $60. every year and is now $450. a month. I'm healthy and take very good care of myself, no meds at all and avoid doctors. The Public Option would make a big difference in my life.

[TomCADem]

14. Lets Say You Get Injured And Are Taken To A Private Hospital

You are on the public option, but lets say the hospital is not. Or, even better, lets say the specialist who runs the X-rays does not accept public option patients. Of course, you are injured, so you aren't exactly price shopping at the moment. You get treated, then a few weeks later, you get a bill for the balance of payments not covered by the public option directly from that specialist after the public option turns down his inflated rate.

That is balance billing.

[Midwestern Democrat]

12. Yes - I've experienced this very issue with a family member. State law

demands that certain emergency patients be taken to the area's designated "trauma center" - and in our case, the designated trauma center was "out of network" - resulting in a huge medical bill. It's really inexcusable that an insurance company can sell policies in a region where the region's only state mandated trauma center is out of the insurer's network.

[TomCADem]

15. This is the point I'm trying to make. For all the attention paid to the PO....

There are some vital areas of reform that very few people pay attention to.

[Phoebe Loosinhouse]

20. WOW! Sickening. nt

[FormerDittoHead]

13. ..but... Our PRESENT system lets you see the doctor of your CHOICE! If you PAY for it! n/t

[shimmergal]

16. The other way to tackle that--

is to make the "balance billing" amounts billed to individuals uncollectible, at least in cases of emergencies where the patient him/herself give informed consent. By uncollectible that means it falls into the same category as debts after the 7-year limit: the hospital can bill you and bug you, and some patients may be scared into paying, but the courts won't give them a judgment or act to enforce it.

Could this possibly get snuck into an innocuous bill somehow?

[mwooldri]

17. Then in a case like above, the out-of-network should be treated in-net by the insurer.

In emergency situations, the out-of-network restriction should not apply.

[TomCADem]

19. It Is Not The Insurer's Restriction. Rather, Its The Lack Of A Contract...

With the provider that results in balance billing, because the out-of-network provider never agreed to the insurer's price schedule. However, in an emergency, the patient really has no choice, but to use the provider. The provider then submits a bill to the insurer, which pays the contract rate, then the provider bills the patient for the inflated balance, hence the name balance billing.

A reasonable limitation would be to limit out of network billing to two or three times the Medicare rate. The insurer would have to pay, but allow the insurer to perhaps charge a slightly higher deductible to the insured to discourage out of network use, but waive this in case of emergency.

There are reasonable ways to address this abusive practice, but we simply do not hear about it, because the public option debate is sucking all the oxygen in the room.

[mwooldri]

21. That's part of the problem... I'm just speaking from own experience with my employer-provided ins.

We have in network and out of network. For out of network the insurance carrier will reimburse what's reasonable and customary and yes the out-of-network provider is then entitled to bill me for the rest. For a couple of places where I have no choice in the matter this is exactly what happens.

However if this was considered to be an emergency situation and the insurance carrier agrees, our employers provision is that this out-of-network coverage to me can be considered in-network and the insurance carrier would then pay the out of network provider the "balance" leaving me with my customary deductible/co-insurance/whatever.

It's this stipulation in my coverage that prevents massive balance billing in the worst of cases - of course my employers then get to enjoy eating the costs but if all health plans had this restriction then eventually I am sure the balance billing situation would be reduced significantly.

Mark.

[snake in the grass]

18. This is simply insane.

Every time I read a story like this I have to ask myself what's wrong with the opponents to health care reform. I understand why the CEOs are against it, but regular people? This could happen to them as well. How dense must one be to act against one's own self-interests (life) with such intensity?