Want to avoid getting "sucker punched" by visiting an in-network hospital with an out-of-network MD?

From John Curry, January 25, 2009
Subject: How to avoid getting "sucker punched" by visiting an in-network facility with an out-of-network MD using our wonderful (?) healthcare system in the U.S. of A.!

MiamiHerald.com
BY JOHN DORSCHNER
Sun, Jan. 25, 2009

In or out of network? Patients get nasty surprises on medical bills

A Gainesville man and his 8-year-old son were visiting South Florida last summer when his son was bitten on the cheek by a dog. Gushing blood, the boy was taken to Homestead Hospital's emergency room. Staffers stopped the bleeding, then recommended he get a plastic surgeon to stitch shut the wound so that it didn't leave an ugly scar.

Lindsey Browning checked and found the hospital was in-network for his Blue Cross Blue Shield plan and his only expense was a $100 co-payment. He says he asked a staffer if the surgeon would be covered by the same co-pay. She said sure.

She was wrong. The surgeon stunned Browning with a $4,100 bill that his insurer said was largely his responsibility because the doctor was out of network.

''This happens all the time,'' says Pat Palmer of Medical Billing Advocates of America. The Brownings had stumbled unwittingly into a central problem with American healthcare, a problem that keeps getting worse as employers and insurers squeeze consumers to pay more through deductibles and penalties for going out of network.

A key problem is being surprised, as were the Brownings, by out-of-network providers in in-network facilities. Whenever possible, Palmer advises consumers to ask insurers and facilities about whether all possible providers are in network.

Finding out the real prices is often difficult for consumers -- and made even harder because federal law prohibits any discussion in emergency room situations that would discourage patients from seeking treatment, a provision that providers sometimes use to explain why they don't talk about network or price issues.

`SUCKER PUNCHES'

''This points to the loopholes, the sucker punches that people get navigating our healthcare system,'' says Gail Shearer of Consumers Union. ``It's ridiculous.''

Earlier this month, out-of-network maneuvers became something of a scandal, as UnitedHealth Group agreed to pay $350 million to settle accusations it cheated on out-of-network claims, which meant that patients often had to pay a larger share of the bills.

Hospitals and providers acknowledge mistakes are sometimes made, but other times they say they are blamed for the policies of hard-hearted insurers and federal law.

Emelio Carullo, the plastic surgeon who sewed up Lake Browning, says that when he goes to an emergency room, ``I do not discuss anything about money. I am not allowed.''

The reason: Federal law prohibits any talk of charges in emergency rooms that might discourage patients from seeking treatment.

Whatever the justification, cases keep piling up. Two patients say that, after visiting Baptist Urgent Care Centers, they were shocked to receive secondary bills running into hundreds of dollars because the centers were in-network, but the physicians in them were out of network.

In another case, Beth Wheeling, a psychologist who understands medical billing as both provider and patient, ran into a problem that is becoming increasingly common for persons with high-deductible policies.

Needing hip surgery after a kayak mishap, she was asked first to get a chest X-ray to make sure she was fit for the operation. She did it at Kendall Regional Medical Center and spent $100 as a co-pay.

When she filed a claim with Blue Cross Blue Shield of Florida, she received an explanation of benefits: The allowed amount for the X-ray was $177, but since she hadn't met her deductible, she owed the entire $177. Since she had already paid $100, she expected a bill from Kendall Regional for $77.

Instead, the hospital charged her $718 for the X-ray and told her she still owed $337.98.

She knew that was wrong. Since the hospital was in her insurer's network, all it could charge was the negotiated rate, even if the patient was responsible for the entire bill.

The $718 on her bill was a gross charge. ''Only South Americans pay that,'' she says, meaning wealthy medical tourists who come to Miami without U.S. insurance.

She wrote letters. She called many times. ``It's just like talking to a wall.''

RARE VICTORY?

Finally, she complained to a Miami Herald reporter, who called the hospital. Spokesman Peter Jude e-mailed back: ``Ms. Wheeling is correct, in that we made a mistake and the account was not adjusted correctly. The Billing Center is now correcting this and the account will have a $0 balance.''

Wheeling wonders how rare her victory was: ``How many of their patients have no knowledge of insurance billing and actually pay these huge charges? . . . People who don't read their EOBs [explanation of benefit forms] are getting screwed.''

In the case of the Baptist Urgent Care Centers, the problems concerned patients with UnitedHealthcare plans.

Last July, Michael Jellson took his son Logan to a Baptist center near South Dixie Highway ''for a small laceration on his chin.'' The center was in his network. The co-pay was $35, and he thought that covered it. Months later, he received a bill from Urgent Care Physicians of Palmetto Bay, stating that it had been paid $265.44 by his insurer, but the doctors demanded he fork over another $366.36.

Jellson complained to Baptist, his insurer and the doctor. ''How was I supposed to know that this particular doctor was not in the network?'' he wrote The Miami Herald's Action Line.

``This was never disclosed to me. . . . What is the point of having the facility be in-network then?''

Julia Moak, a schoolteacher and single mom, had the same experience. For three years, she had used Baptist urgent care for a $25 co-pay.

This year, she and her son went there four times. Months later, the out-of-network doctors demanded another $1,131.70. When she didn't pay, a collection agency harassed her. She made calls and wrote letters. Nothing happened.

When Action Line and a Miami Herald business reporter asked Baptist Health South Florida about the billing issues, Vice President Eric Shatanof acknowledged that there had been a problem with the doctors, who were independent contractors, not employees of Baptist Health.

After long conversations with the doctors, they are now in the same networks that Baptist uses.

BILLS ADJUSTED

Patients who complained about getting extra bills from urgent care doctors were having their bills adjusted so that ''they are only responsible for their co-pay,'' Shatanof says.

Moak says Baptist told her the doctor bill was fixed, but she wonders how many other patients might have paid the out-of-network claims. ''They say this was going on for at least eight months,'' in at least two centers. ``That could be a lot of people.''

Shatanof says he doesn't think so. Baptist has heard only from a few patients. ``All those issues have been addressed.''

However, as of Thursday, Jellson said he had yet to hear from Baptist.

More problematic is the case of Lake Browning, the 8-year-old bitten by the dog. He was treated first in the Homestead ER, but the staff suggested that, to minimize the scar, it would be best to see a plastic surgeon at the Baptist Hospital ER.

At Baptist, Carullo sewed up the boy's face. That took about 20 or 30 minutes, the father estimates. Because they needed to return quickly to their Gainesville home, Carullo offered to reexamine the wound in his Coral Gables office the next day, a Sunday.

''He still has a scar,'' says father Lindsey, ''but maybe it's a little smaller scar'' than if an ER doctor had done it.

Then came the bill: $3,400 for the stitching, $750 for the office visit. Because the doctor was out of network, the family's Blue Cross Blue Shield policy covered $600. The doctor insisted the Brownings pay the rest.

Browning complained to Baptist, to BCBS, to the doctor. Karen Godfrey, a Baptist executive, says there is some dispute about what Browning asked the hospital staff about Carullo being covered and what the staff responded. ``But at the end of the day, the plastic surgeon was not in network.''

Godfrey says Baptist had ''multiple conversations'' with the plastic surgeon, who agreed to take off the $700 charge for the office visit. Because the dog bite occurred at his in-laws, their homeowners insurance paid another $2,000 to the doctor, meaning about $700 of the bill is still outstanding.

BCBS and Carullo say they can't discuss individual cases because of privacy laws. But the surgeon adds, ''it's the patient's responsibility'' to pay.

''I'm blessed,'' says Browning, ``because I can pay this bill without too much struggling, but I'm wondering how many people out there are being surprised by these huge bills and can't afford them.''

Palmer, of Billing Advocates, says it's flat-out wrong that an in-network clinic or hospital would use out-of-network staff without warning patients.

''This is a pet peeve,'' she says. ''The surgeon's in network, the anesthesiologist is out of network. Does a patient think to ask about the anesthesiologist? The pathologist?'' asks.

If hospitals and clinics have out-of-network staff, Palmer says patients should be warned up front.

'They should get a document to sign: `I understand you're going to rip me off.' ''

ILLEGAL WARNING

Carullo and Baptist say such a warning would be illegal in the emergency room. Federal law requires that anyone who comes to an ER must be treated, regardless of ability to pay.

Hospitals that reveal the expense of care could be fined for attempting to scare patients away.

Nationwide, out-of-network costs have become a hot topic. Earlier this month, UnitedHealthcare agreed to pay $350 million to doctors and patients to settle allegations that the insurer has paid too little to out-of-network providers.

For patients, the problem is that the out-of-network provider then demands the rest be paid by the patient out of his own pocket.

Palmer says such charges can be so huge that the patient sometimes might be better off telling the hospital they are uninsured. Some places demand full-charge payment from insured patients who are out of network, ``but they take 35 percent off for the uninsured.''

http://www.miamiherald.com/business/v-print/story/871576.html