Huge ‘balance bills’ surprise patients after ER visits
14th March 2016 · 0 Comments
By Susan Buchanan
Contributing Writer
Last week, state Insurance Commissioner Jim Donelon said he has publicly opposed “balance billing” by hospitals during his nine years in office. To control their own costs, many New Orleans-area hospitals use outsourced doctors, particularly to staff emergency rooms. An insured patient visits ER at a hospital in his network but may be unaware that the unit’s doctors aren’t in network. An outsourced physicians’ group sends the patient an unexpected and often hefty “balance bill,” demanding payment for ER treatment.
Insurers and hospitals say these ER bills can be meditated or negotiated. But according to Commissioner Donelon, that isn’t easy, especially since in-state efforts to prohibit the practice have failed. “Bills have been introduced in nearly every recent Louisiana legislative session to outlaw balance billing but opposition from hospitals, insurers and doctors has been too strong,” Donelon said. “A bill was introduced by appropriations chairman Jim Fannin in 2013, and even his considerable skills couldn’t get it passed.” Fannin is a Republican from Jonesboro. In the legislature’s 2014 regular session, HB 822, introduced by Republican Rep. Alan Seabaugh from Shreveport, went nowhere.
Balance billing is legal federally and has been around for at least 20 years, Donelon said. But it’s either outlawed or partly restricted in a number of states, including California, Illinois, New York, Texas and Florida.
The Affordable Care Act, or Obamacare, addresses medical billing but it doesn’t repair the balance-billing problem in Louisiana, and it may inadvertently make the practice more frequent, Donelon said. Some ACA plans have limited networks that can increase the use of balance billing. And for non-ER physician charges, the ACA caps out-of-pocket expenses but not charges from of out-of-network providers.
Last week, Blue Cross Blue Shield of Louisiana spokeswoman Dianne Eysink in Baton Rouge said an in-network hospital might hire an external physicians’ group to supplement its ability to deliver care. But that group might choose not to contract with an insurance company. “Unfortunately, in these cases, the providers can bill our customers beyond the allowable amount because they aren’t in our network and haven’t agreed to the same amounts as in-network providers,” Eysink said. “In this situation, Blue Cross pays the ‘allowable charge.’ But because there’s no contract with the ER physicians’ group, those doctors are free to balance bill customers, charging them for anything beyond what Blue Cross pays.”
BCBSLA tries to make healthcare consumer friendly but ER outsourcing is “one of those difficult cases with no simple answer,” Eysink said. “As of today, however, more than 70 percent of emergency room doctors in the state are in the BCBS network. We’re actively working with out-of-network ER physician groups to try to get them to contract with us to avoid this issue.”
Sarah Balyeat, Tulane Medical Center spokeswoman, said that facility—like most hospitals nationally—has outsourced ER physicians for years “Our current provider is the Schumacher Group,” she said. “It cooperatively negotiates with every insurance company in good faith to obtain fair and reasonable rates of reimbursement that adequately recognize the high-quality, emergency care delivered.”
Balyeat said that while Schumacher Group is in discussions with many insurance companies, “it may not be in contract with various plans.” Nonetheless, “it accepts what Blue Cross Blue Shield bills the patient for no more than their co-insurance and deductible obligations,” she said.
Balyeat didn’t acknowledge that Schumacher Group mails demands for payment to insured patients for ER work at Tulane Medical Center. This summer, a BCBSLA-enrolled employee of The Louisiana Weekly received one of these notices from Independent Emergency Group LLC after visiting TMC’s ER on a holiday. Balyeat admitted that Independent is “one and the same as Schumacher.” In a medical emergency, an ER visit by this newspaper’s employee requires a co-pay at a network hospital but beyond that the insurance company typically picks up the tab. After TMC’s ER treated her cut finger, this paper’s employee was alarmed to learn she owed Independent Emergency Group LLC more than $1,500.
At Touro Infirmary, all of its ER doctors are provided by the Schumacher Group, Touro’s medical staff office said last week, without elaborating.
On its website, Schumacher Group says it has career opportunities for doctors in emergency and/or hospital medicine at the following area facilities: New Orleans East Hospital, Ochsner Medical Center, Touro Infirmary, Tulane Lakeside Hospital and Tulane University Hospital.
An Ochsner spokeswoman last week declined to comment on ER staffing. But at the new University Medical Center New Orleans, “our emergency department is staffed by LSU emergency medicine so we don’t outsource,” LCMC spokeswoman Siona LaFrance said. UMC opened its doors on Canal St. on August 1. As for Children’s Hospital, its emergency room is staffed by Children’s own doctors, spokeswoman Cathleen Randon said.
Eysink at BCBSLA said Schumacher files claims directly with Blue Cross. “And then we pay the allowable charge to the ER doctor groups directly,” she said. The bill that was mailed out by Independent Emergency Group LLC to this newspaper’s employee could have been a mistake, she said.
Press officers at TMC and BCBSLA offered to have their companies take a look at this demand for payment as soon as they learned The Louisiana Weekly was working a consumer story on balance billing. Then on August 1, Schumacher Group, not Independent Emergency Group, sent a letter to the paper’s employee saying BCBS had reimbursed them and her balance was zero. It’s unclear if Schumacher was alerted by the press officers, or if it wrote off the charges independently.
At Kentucky-based insurers Humana, “if a medical bill is for emergency services, Humana pays the claim as in network, regardless of whether the hospital is in our provider network or not,” company spokesman Mitch Lubitz said. For the most part, hospitals in New Orleans and Louisiana contract with outside physicians for ER service, he noted.
“If a customer receives a balance bill, they can call the hospital’s or doctor’s billing office and ask them to take what Blue Cross paid them as payment in full,” Eysink said. But Commissioner Donelon said without a federal or Louisiana law prohibiting balance billing, a patient can meet resistance trying to get a charge eliminated.
BCBSLA informs its customers when a hospital is in network but its doctors aren’t. “In that situation, we mail letters to customers within 30 miles of the facility,” Eysink said. “A list of nearby hospitals with in-network doctors is included in the letter. And we send out a list of urgent care centers and retail health providers that are in network. We include a pamphlet outlining the best types of providers to seek care from under what circumstances. We share this information with our network physicians so that they can help us inform their patients.”
A site listing BCBSLA emergency-room and other hospital-based doctors is www.bcbsla.com/hbp, and a resource for its in-network doctors and hospitals is www.bcbsla.com/findcare, Eysink said. Policy holders can phone customer service at the number on their ID card to ask if a doctor or facility is in network. They can create accounts at www.bcbsla.com/activate to find network doctors from phones, tablets and computers. These searches can be done on iPhone and Android apps, she said.
Negotiating bills with insurers takes time, however, and that’s something most full-time workers and parents don’t have. Trying to navigate healthcare laws and understand insurance polices is frustrating. After receiving a balance bill, many consumers simply write out a check, assuming they have no other choice. “We really need a law on the books if we’re to prevent balance-billing abuse in Louisiana,” Commissioner Donelon said. He plans to keep working towards that goal.
This article originally published in the August 10, 2015 print edition of The Louisiana Weekly newspaper.
