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THE MUSINGS OF A TRADITIONAL SOUTHERN DEMOCRAT

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Sid in his law office where he sits when meeting with clients. Observant eyes will notice the statuette of one of Sid's favorite Democrats.

Friday, June 12, 2015

Surprise Bills for Many Under Health Law - Out-of-network charges often aren’t flagged before treatment, consumers say; states tightening laws

From The Wall Street Journal:

Many consumers with health coverage through the Affordable Care Act are facing unexpected medical bills that in some cases greatly exceed the law’s caps on out-of-pocket expenses.

The law’s limits don’t apply to charges from out-of-network providers, and many insurance plans sold on ACA exchanges have limited networks—amplifying the risk of surprise bills.

Health plans offered by employers also have been slimming down the number of doctors and hospitals in their networks. But what have come to be known as narrow networks are more prevalent in plans offered on the health law’s exchanges, one tactic insurers are using to curtail costs because they can’t exclude consumers with existing medical conditions.

Under the ACA, patients generally can’t be charged higher coinsurance or copayments for out-of-network emergency-room services—but they can be charged for the amount insurance doesn’t cover, which could be thousands of dollars. The law caps out-of-pocket costs in 2015 at $6,600 for an individual and $13,200 for a family. But that doesn’t apply to out-of-network providers who charge patients for the part of bills that their insurance doesn’t pay.

More states are passing laws that aim to halt unexpected out-of-network bills. Under California legislation approved this month, consumers who go to an in-network facility but are treated by an out-of-network provider there only have to pay what they would have been charged if the provider participated in their plan.

It can be easy for patients to accidentally step outside their plan because of outdated information about provider networks. Moreover, a patient who picks a hospital that is in network may discover that some of the doctors who provide treatment there aren’t.

“This issue is becoming more urgent because you have more people covered under the ACA, and more of them are in the lower-income levels and can’t afford financial surprises,” said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition.

Dr. Jay Kaplan, president-elect of the American College of Emergency Physicians, said insurance reimbursements are so low that doctors have to bill for the difference or go out of business.
America’s Health Insurance Plans, a trade group for insurers, says out-of-network physician charges can be significantly higher that customary rates.

The group has supported protections for consumers against balance billing—charging patients for the part of the bill that insurance doesn’t pay.

Plans with narrow networks make up about half of all health-law exchange networks in the U.S., and about two-thirds of the networks in the largest cities, according to a 2015 report by McKinsey & Co. Among companies with 50 or more workers that provide insurance, 8% offered a narrow-network plan in 2014, according to a report by the Kaiser Family Foundation.

More than half of Americans say making sure health plans have sufficient networks to provide a wide choice of doctors and hospitals should be a top health-care priority for the president and Congress, according to an April poll by the foundation.

“We are concerned about the way some health insurers are marketing their products and setting arbitrary limitations on out-of-network coverage that negatively impact patients’ out of network costs,” said Dr. Robert Wah, whose terms as president of the American Medical Association ended this week.

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