Wes Bailey, a resident of Nashville, Tenn., sought emergency treatment for back pain. He chose a hospital in his insurance network to ease the financial burden. To his surprise, in addition to his $1,900 ER bill, he received a separate $600 fee from an out-of-network ER physician, according to USA Today.
This practice known as "balance billing" forces patients to pay the difference between the insurance plan's out-of-network benefits and the provider's rack-rate charge. Many patients are uninformed about this billing method, and there is rising concern amongst patient advocates and legislators that the billing practice places excessive burden on patients.
Here are six things to know about patients, providers and balance billing.
1. Erin Fuse Brown, an assistant law professor and faculty member of Georgia State University's Center for Law, Health and Society in Atlanta, told USA Today balance billing charges can be two, three, five or 10 times more than the negotiated rate.
2. It can be challenging for patients to check the network status of any physician they may come in contact with. "You as a patient really have no mechanism to find out ahead of time if they are in network or out of network," Benjamin Sanders, executive director of government affairs for Farm Bureau Health Plans, told USA Today.
3. It's generally not a hospital requirement for physicians who work there to be in network. "We are sensitive to additional bills that patients may receive from affiliated physicians that practice at our hospitals," said Kimberly Johnson, director of communications for Brentwood, Tenn.-based TriStar Health, in USA Today. "We encourage those physicians to participate in the same insurance contracts in which our hospitals participate." Mr. Bailey sought treatment at TriStar Health ER.
4. According to USA Today, Farm Bureau Insurance of Tennessee is working with state Rep. Ron Travis on legislation aimed at reducing some surprise billing situations. Under said legislation, physicians would have to notify a patient about out-of-network provider's participation in their care before a scheduled procedure.
5. The Tennessee Medical Association agrees that patients are often shortchanged by balanced billing, but the organization also wants a solution that doesn't place added responsibility on the physician, citing that providers may not have immediate access to the patient's complete insurance information, according to USA Today.
6. Yarnell Beatty, TMA's vice president of advocacy and general counsel, told USA Today that over half of patient bills go unpaid. Mr. Beatty also suggested that this issue should place the "adequacy of networks" under scrutiny. "Who are you going to penalize, the healthcare provider who has studied for years to learn his craft and has the right to negotiate with the payers that are being reasonable?" Mr. Beatty said. "There are a lot of downsides to having any kind of mandates. It's not fair to the provider. It's not fair to the patient."
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