Reform or no reform, insurers will weasel on “out of network” loopholes

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The Washington Post today has an eye-opening story today on how a family ended up in crushing debt at an "in-network" hospital apparently jammed with out-of-network doctors. Tens of thousands of dollars later, their little boy’s rare and deadly heart defect is at least semi-fixed, but the family finances are in ruins. It’s a problem that won’t be fixed by reforms that rely on the private insurance industry. But it’s also a problem that Congress can partly cure, with or without bigger reforms.

Anyone  who’s had to enter a hospital lately knows the perils of confronting a doctor who’s not in their health insurer’s "network." Anesthesiologists and radiologists in particular refuse to take insurance payments, but good luck on finding who’s in and who’s out of network as you’re wheeled to the operating room. Even requesting an in-network anesthesiologist in advance guarantees nothing. When the bills come rolling in later, your insurer pays its "out-of-network" fee and washes its hands of you.

The Post story, by Jordan Rau of the independent Kaiser Health News, is about the Lemacks family of Virginia. They knew LemackFamily.pngthe surgeon who operated on their newborn was out of insurer Aetna’s physician network, but had gotten Aetna’s permission to go to him and expected the nationwide insurance company would help deal with his billing. Wrong. Other doctors and technicians who treated the infant were also, unbeknownst to the familly, out of network. More than $100,000 in bills rolled in, and they were cut adrift by Aetna to negotiate what paltry deals they could.

The little boy is six now and pretty healthy. The family’s finances are still in a stranglehold of collection agencies as they try to pay down their balance.

Such "balance bills," along with annual and lifetime limits on health care coverage, are a leading cause of medical bankruptcy in America. And the current health reform bills, even if one passes, won’t fix balance billing.

Patients shouldn’t be left to fight a battle that should be between doctors and insurers–insured families are now stuck with astronmical bills because they’re politically the weakest link. Insurers should be required to deal directly with out of network doctors who treat patients in emergency situations. Patients need assurance that when they go to an "in network" hospital that their treatment in the hospital will be "in network." And when an insurer agrees that an out of network doctor is needed for a rare or tough situation, it should reach agreement on billing beforehand. In any case, both hospital and doctor rates for most procedures should be made public, not stay secret until after the fact.

Such common-sense reforms, included in Consumer Watchdog’s "Bill of Rights" for patients, would at least help insured people in the here and now, with or without wider reforms.

Consumer Watchdog
Consumer Watchdog
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