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Daily Archives: November 11, 2014

Network Blues: Big Bills Surprise Some E.R. Patients

“In-network” and “out-of-network” – for people with health insurance, those words mean one thing: money. If you don’t want to get charged extra, you get your treatment done in-network. It sounds straightforward, but sometimes it doesn’t work out that way, even when patients think they’re playing by the rules.

Jeffrey Craig Hopper, a probate attorney in Austin, Texas, knows all about following the rules. Still, accidents happen. Last June he was coaching a Little League practice session when an errant baseball smashed into his face.

His wife Jennifer Hopper remembers rushing to the field.

“His eye was swollen shut enough that we weren’t sure if he could see,” she said.

Even in that moment of panic, Jennifer made absolutely sure to drive him to a hospital in Austin that was part of their insurance network.

In the end, Jeffrey was okay. He broke some facial bones around his eye, but they healed and his vision was fine. The family settled the co-payments for the emergency room but was surprised when they later received a separate bill for more than $700 from the emergency department doctor.

Last June, a baseball hit Jeffrey Craig Hopper, a Little League coach in Austin, Texas, in the eye. Hopper and his family were surprised that an out-of-network doctor treated him at an in-network hospital. (Photo by Jennifer Hopper)

“It felt kind of random,” Jennifer said. “How do I know who’s going to charge me, and who’s not going to? So that was the first question.”

Like many patients, the Hoppers assumed that doctors working at an in-network hospital would, of course, be “in network.”

As it turns out, that’s not necessarily true. Emergency room doctors, radiologists and anesthesiologists often don’t work for the hospital. They work for themselves, often in large practice groups, and it’s up to the doctors to sign their own deals with insurance companies.

Many of them don’t. In those situations, the doctors can bill the patient for whatever the insurance company wouldn’t cover  because the care took place outside of the approved network, a practice known as balance billing.

“I couldn’t let that go, it just felt wrong,” Jennifer said. “Because there was no way out. There was obviously no way we could have avoided the situation, given our emergency.”

The Center for Public Policy Priorities, a left-leaning Austin think tank, recently analyzed ER billing by the three biggest insurers in Texas – Humana, Blue Cross and United.

Its report found that in over half of Humana’s Texas hospitals, none of the ER doctors was actually in Humana’s network. For United, this occurred at just under half of the hospitals and for Blue Cross, at about a fifth.

The report’s author, Stacey Pogue, said balance billing is unfair to patients.

“No other consumer services are sold to us this way,” she said. “It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately. And some of them will negotiate with you on the price, and some of them will accept coupons, and the others don’t.”

The Texas insurance industry has said it would like ER doctors to join their networks, but it can’t force them to.

The ER doctors counter that insurance companies often don’t pay them enough when they join networks.

This story is part of a partnership that includes Houston Public Media, NPR and Kaiser Health News. It can be republished for free. (details)logo npr

The economics of ERs are complex, explained Dr. Bruce Moskow, president of the Texas College of Emergency Physicians.

“In an emergency department, we see everyone and we’re not even legally allowed to ask if they’re going to pay their bill,” Moskow said. “Large numbers of people pay nothing.”

There is a mediation process in Texas for some of these out-of-network bills, but it’s only for certain types of insurance and certain situations.

Some states have tried to tackle the problem in different ways. In California, ER doctors can’t send a separate bill to HMO patients. In New York, a newly-passed law requires out-of-network doctors and insurers to hash out payment on their own, and leave patients out of it.

Texas insurers have indicated they’d be receptive to more changes, such as expanding the mediation process. It’s currently restricted to balance bills over $1,000 and certain types of PPOs.

“Just get the consumer out of it,” said Jamie Dudensing, the CEO of The Texas Association of Health Plans. “If you just leave it between the health plan and the physician, the consumer’s not dealing with this issue. Let us work this out through the private market.”

Jennifer Hopper said she spent weeks appealing the physician’s bill, going back and forth between the doctor and the insurance carrier. Eventually she filed a complaint with state regulators. After that, her insurer ended up paying part of the physician’s bill.

People are typically advised to do their “homework” ahead of time and know who’s in their network and who isn’t. But Pogue said that isn’t always possible, especially in an emergency.

“If you’re wheeled into the emergency room door, you can’t ask the emergency room physician who runs up to stabilize you ‘Are you in network or out-of-network?’” she said. “That physician needs to be concentrating at that point on giving you life-saving care, not rattling off the list of insurance companies that he or she contracts with.”

Hopper has tried to do her homework by figuring out where to go for a possible future ER visit. Online, she searched her health plan to find ER doctors who were in-network. But she found less than five at the hospitals her plan used in Austin. She doubts the odds of getting those doctors the next time she or a family member needs care.

“So the reality is, all the transparency in the world doesn’t change the fact that knowing everything, I could not be sure I would get a different outcome,” she said.

This story is part of a reporting partnership that includes Houston Public Media, NPR and Kaiser Health News.

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Medicare Proposes Coverage Of Low-Dose CT Scans To Detect Lung Cancer

Andrea Borondy Kitt’s husband Dan lived for a year and a half after his October 2ዋ lung cancer diagnosis. She’s convinced, however, that he might have lived longer had Medicare paid for a low-dose CT scan of his lungs that could have caught his cancer in the early stages.

Nine months before his diagnosis, Andrea read about this test, which had demonstrated encouraging rates of detecting early stage lung-cancers in long-time smokers. She wanted Dan to be screened. But her husband, a 40-year smoker who had quit eleven years earlier, wouldn’t do it because Medicare didn’t cover it.

But in a Monday announcement, Medicare officials signaled this policy is about to change.

The draft decision by the Centers for Medicare & Medicaid Services would provide coverage for this test to an estimated 4 million Medicare beneficiaries. To qualify, the beneficiaries would have to be younger than 74 and, asymptomatic for lung cancer, but have pack-a-day habit for at least 30 years. Those who quit as long as 15 years ago would still be eligible for the screening.

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Based on an analysis published in the journal American Health and Drug Benefits, the average cost of the low-dose CT lung cancer screening would be about $241 per person screened for Medicare.

The health law required as part of its essential health benefits provision that insurers cover this screening. But Medicare – not part of this mandate – has lagged behind.

In addition, the U.S. Preventive Services Task Force in 2013 recommended the low-dose CT scan for heavy smokers aged 55 to 80.

Lung cancer kills approximately綠,000 people each year and is the leading cause of cancer deaths in the United States, according to National Cancer Society statistics. It also has a poor prognosis, notes the USPSTF. About 90 percent of people who have the disease die of it. However, when diagnosed early, the prognosis improves and the cancer can often be treated surgically.

The treatments for the late stages include chemotherapy and radiation, both of which are often debilitating for patients, said Ella Kazerooni, the director of cardiothoracic radiology at the University of Michigan Health System. She said catching it early means doctors have a much better chance of finding a curable treatment.

“It’s both rewarding when you do catch it early, and you’re going for curable treatment — it’s a phenomenal place to be,” said Kazerooni, also the chair of the American College of Radiology and Lung Cancer Screening Committee. “For the great majority of people present, by the time they have symptoms it’s unfortunately spread too far.”

However, some critics have expressed concern about the risks of false positive results and over diagnosis. A “substantial proportion” of false-positive results occur, according to the USPSTF, and, though additional imaging can resolve most of these findings, some patients may require invasive procedures.

This KHN story can be republished for free (details).

“The benefits of this have been overestimated, and the harms have been underestimated,” said Russ Harris, a professor of medicine at the University of North Carolina, Chapel Hill.  “If people were better informed, they would understand … the limitation of the screening’s benefit.”

Others cautioned that patients should not be misled into thinking that the screening is the counterweight to a serious public health problem. “Even with the screening, some people will still die … but this is secondary prevention,” said Alfred Munzer, former American Lung Association president and chair of Action on Smoking and Health. “It is a way of preventing people from dying from lung cancer, and it’s one that comes late in the game, but we have people who’ve smoked their whole lives and we have to care for those people.”

Meanwhile, Andrea Kitts understands that even if her husband had the test, it may not have identified his cancer at an early state. Still, she wishes he would have had the option of low-dose CT scan. “We can stop this. If lung cancer screening had been there, I might not be talking on the phone to you, but now the rest of my life is dedicated to lung cancer.”

The proposal, which would not be finalized until February, is now subject to a 30-day comment period. Such draft decisions are rarely reversed or significantly altered.

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Impact of So-Called 'Cadillac' Tax

The tax on high-cost health plans, which are often referred to as Cadillac plans, is expected to impact a considerable share of the plans provided by healthcare organizations for their own employees, as much as ȇ% by 2020. The implications are significant because the excess-benefits tax requires the employer to payń0% on the value of the portion of the plan that exceeds thresholds set by the Patient Protection and Affordable Care Act. Employers also need to consider that the tax is measured as a direct function of plan cost, and not actuarial plan value, and that a number of factors can drive excise-tax exposure.

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Viewpoints: Court Could Undermine Health Enrollment; Losing Control Of Mental Hospitals

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State Highlights: Judge Skeptical Over Partners Deal In Mass.; S.C. Gets New Medicaid Director

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VA Chief Pushes Overhaul, Firings At Agency

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Pain Doctors Profit From Drug Tests On Seniors

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Kansas Hospitals Continue Push For Medicaid Expansion

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Kentucky Offers Range Of Ways To Enroll In New Coverage

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The Countdown’s On To Nov. 15 Enrollment

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