'Balance billing' can trip up patients who have insurance

[marmar]

from the Dallas Morning News:



'Balance billing' can trip up patients who have insurance
12:00 AM CDT on Sunday, October 25, 2009

By JASON ROBERSON / The Dallas Morning News
[e-mail]


When Thomas Harrington went to the emergency room for treatment of a smashed finger one Sunday morning in August 2007, he fully expected his insurance would cover his costs.

The hospital, Denton Regional Medical Center, was included in his insurer's network, after all.

Unfortunately for Harrington, the emergency room doctor was not.

As a result, the 48-year-old Denton man was billed for the balance not paid by his insurer.

"The next thing I know, I checked my credit report and saw that the doctor submitted $350 to collections," Harrington said. That debt lowered his credit score from 775 to 630, he said.

Harrington was caught by a practice known as balance billing, which typically occurs when a patient visits a hospital in his insurer's network and is treated by hospital-based physicians, such as anesthesiologists and radiologists, who are not in the network. ..........(more)

The complete piece is at: http://www.dallasnews.com/sharedcontent/dws/bus/stories/DN-medicaldebtside_25bus.ART.State.Edition1.3cf9a59.html

[Quantess]

1. Insurance companies will do anything to avoid paying.

It's ridiculous.

[wtmusic]

2. Do you blame them?

Most businesses will do anything to avoid paying, as will most citizens. That's captitalism.

And that's why unregulated capitalism fails miserably at healthcare. It's far too complicated (intentionally), by people whose business it is to make money, for patients to stand a chance.

[MrModerate]

4. Shirking your obligations and gaming the system are not inherently . . .

"Capitalistic." That's human nature unrestrained by social norms and can be seen in every economic system ever devised.

Otherwise I agree with you. Capitalism is not the right model for the provision of basic citizen services, except to the extent that a robust capitalistic system is supposed to lead to sufficient government resources to pay for human welfare initiatives that really are the government's natural responsibility.

[wtmusic]

9. If the insurance company is not breaking the law

what obligations are they shirking? The ones you've decided are proper? Is it also up to you to decide what "gaming the system" means?

Social norms are that companies will do whatever they can to save money, and that's the essence of capitalism.

[MrModerate]

11. The obligation to perform as advertised. The insured had a reasonable presumption . . .

that by going to an in-network provider, he would be covered to the limits his policy stated. The contract between the facility and the insurer did not provide the expected coverage. And although it's not stated explicitly, the implication is that the charges were not communicated to the insured, so he suffered additional harm through damage to his credit report. That fits my definition of shirking responsibiity.

Yes, I am allowed to evaluate what I think "gaming the system" means. You are too. Please feel free.

The fact that companies will do whatever they can to save money -- while not always true -- is generally so. It just doesn't have any unique application to capitalism (let alone being the "essence" of capitalism). It has to do with economics, but economics is much broader than capitalism.

[wtmusic]

12. You can define "shirking" and "gaming" however you like

but don't be disappointed if the rest of world doesn't think your definitions are particularly significant.

"Reasonable presumption", "damages", and "implied" do have significance in a legal sense, but only in civil law. The goal of health care reform is to create a body of criminal law so that individuals don't waste their time and resources to litigate these nebulous arrangements.

Companies don't have any unique application to capitalism? :silly:

[MrModerate]

13. I'm getting the feeling I'm shouting in a deaf ear, but I'll give it one more shot.

You are representing your opinion as "the rest of the world." That's a bit presumptuous, particularly when the evidence around you is that your opinion is significantly in the minority. However, if you want to consider my definitions insignificant, please be my guest.

However, the "reasonable presumption" that insurance companies are "shirking their responsibilities" is a major driver of health care reform. If they were doing such a great job (e.g., "performing as advertised") there would be very little incentive to reform the system at all. Those terms are as applicable to the marketplace of ideas as they are in court. Possibly because legal arguments are a traditional mechanism to resolve issues that arise in society generally.

Also, "companies will do whatever they can to save money, and that's the essence of capitalism" is just plain wrong. Capital is the essence of capitalism. It's simply good business practice to not expend funds unnecessarily, and good business practice is not unique to capitalism. Any business, any government agency, any individual craftsman or tradesman -- in any economic system whatsoever -- is enjoined from expending funds needlessly. To attempt to impugn capitalism as essentially concerned with not spending money needlessly is rather silly. Perhaps your rhetoric ran away with your intentions.

Finally, where insurance companies have run afoul of social norms is not through their application of reasonable means to avoid unnecessary expense, but through genuinely evil wastage of the premiums entrusted to them as "insurance," and their attempts to cheat their customers (through "gaming the system" among other methods) to support that wastage. That also isn't capitalism, it's parasitism, and any society has a right to resist parasites.

[wtmusic]

14. You'd make a lousy lawyer.

The significance of one's opinion is independent of what that opinion actually is. You might want to mull that over before you embarrass yourself again.

I noticed you're using quotes around your terms this time. Maybe that's because you've realized that these are loaded words that have no significance in criminal law. I hope so.

Maybe you can explain to me how a business would work outside capitalism. Then look up the definition of "enjoin" and tell me how that relates to what you're trying to say.

Sorry if I seem combative, but I get tired of people throwing out big words without knowing the fuck of what they speak.

[MrModerate]

15. I detect a pattern here. First you offer your opinion -- inaccurately --

as that held by the rest of the world. And then you go on to offer the opinion that I should be embarassed because I don't agree with you.

Funny, I don't feel embarassed. Projection much? Perhaps you should consider getting a clue before offering one to others.

Incidentally, I used quotes around my terms as an aid to the reader to navigate the thought process represented in my argument. Silly me, it just seemed the right thing to do, given your continuing incomprehension.

And please tell me you don't think that there is no business that takes place outside the capitalist system. While capitalism is, IMO, the most efficient business system at meeting people's needs (warts and all), it is far from the only system. Socialism? Communism? Following is a short 9th-grade lesson on the three main economic systems I've mentioned. Give it a look. http://tutor_me.tripod.com/book/econsys.htm

And "enjoin." Let's see: "1. to order or direct (a person, etc.) to do something; prescribe (a course of action, etc.) with authority or emphasis" (Macquarie Online Dictionary). Well, I will be dipped in shit if that isn't *exactly* what I meant to say. What's your problem?

Sorry if I seem dismissive, but I often dismiss people who spout nonsense and then get all huffy about it.

[WillowTree]

17. You probably don't know it, and probably don't want to, but you just stated the problem.

The insurer's contract is with the facility, not the ER doctor. For whatever reason, in this case (and a fair percentage of cases), there is no contract with the physicians. As often as not, that's because the physician's choose not to contract with the insurance companies and thus agree to accept the "in network" reimbursement amounts as payment-in-full. There was a time when this wasn't an issue because most hospital-based doctors' charges were billed as part of the hospital bill and were reimbursed to the doctors by the hospital. But HCFA (Medicare) mandated that practice away, so now the bills come separately and are processed separately based on whether or not the billing provider is contracted or not. No "gaming the system" involved.

[MrModerate]

19. Surely the insurer realizes that their customers will be exposed to this billing practice?

And can include instructions or provisions to mitigate such shock payments?

In this case the insured didn't seem to be aware of the practice, and I'd think the insurer has a responsibility -- at minimum -- to educate the policyholder that they're at risk. And I don't mean in the 4-point type in the back of the policy, but as a part of the general understanding that any policyholder needs to have. Anything short of comprehensive disclosure (including what the policyholder can do to avoid such charges) strikes me as the insurer "gaming the system" -- in essence, offering less value than a reasonable person would think they were getting.

[HughMoran]

20. Perhaps insurance companies will reconsider when someone goes postal on them

I'm surprised it hasn't happened already as you see stories like this on crime dramas :)

[glitch]

5. Very much.

And no, most businesses and citizens will NOT "do anything to avoid paying". Most criminals will, but most businesses are not criminal.

The Bush Years greatly blurred the line but there is still a distinction. Your cynicism is understandable but incorrect. IMO.

[wtmusic]

10. I should clarify

Most businesses will do anything legal to avoid paying

[MichiganVote]

6. Yes I do. When they do not provide reasonable consent for a fee that has not been fully

explained to the insured in something other than fine minuscule print--I do blame an insurance company for poor business practices. That's not capitalism. That's corruption and you need to recognize the difference. I don't agree with your premise that "most businesses will do anything to avoid paying, as will most citizens". That is not a statement that you can support with data and since you have not, I assume it to be a belief that you have rather than a statement of fact.

[wtmusic]

8. From the insurance company's point of view:

they say, "Mr. Denton will do anything to avoid paying his bill."

What you see as "poor business practices" are thought of as frugal and sound from the point of view of the company.

No, it's not corruption - and you need to see the difference. It's legal, and that's the problem.

[MichiganVote]

18. Not everyone believes that insurance companies define reality.

[surrealAmerican]

3. yet another shady insurance practice ...

... that needs to end.

[WillowTree]

16. Not really.

In every case that I've ever seen when something happens like this, a simple call to CS at the insurance company to point out that the patient went to a network hospital and had no choice as to which pathologist/radiologist/ER doc/anesthesiologist they got is enough for the company to re-process at the in-network rate. And I saw quite a few cases like that while I was consulting at a physician's billing service.

The problem occurs because most of these hospital-based physician's bills are fairly simple, cut & dry and, as such, they often get "auto-processed" with little if any human intervention and the system doesn't know what facility was used, just that the billing physician is not in-network based on the billing ID. I never encountered a case where the company did not fairly readily agree to re-process as "in network". Even UniCare, and they're the most unyeilding, uncooperative SOBs I've ever dealt with on most things.

[Bitwit1234]

7. That happened to me in a way BUT

my insurance company sent a check to me which covered the doctor. Then I had to wait til I was billed. Deposit the check and write one for the service. They told me to do this so that the patient number etc matched up to the doctor service and I got credit for paying it. I have BC/BS from another state plus medicare and they always pay what medicare doesn't. I guess I am lucky. I hear so many horror stories from people I know.

My next door neighbor died with lung cancer and I know why. He worked for WalMart and was not fully covered. He wouldn't go to the doctor because he didn't want to leave his wife with all those bills. He stayed home and suffered till a month before he passed away.