Boca woman’s $82,000 surprise medical bill draws focus in state forum

A Boca Raton woman was diagnosed with a brain tumor. She went to a hospital in her health plan’s network.

What she did not see coming: a surgeon not in the network billed $85,000. To her shock, she was told she had to pay $81,890, on top of other charges and premiums.

Florida insurance consumer advocate Sha’Ron James cited that example among others Thursday in a forum designed to help Florida legislators take a fresh look at surprise medical bills after efforts to tackle it stalled last spring.

The woman contacted James’s office after reading an article in The Palm Beach Post, officials said.

“She had to cash in an IRA to pay off bills,” James said.

As if medical problems were not scary enough, surprise bills have led to wiped-out savings, bankruptcy, ruined credit and other disasters for consumers.

“The challenge is how to balance insurer and provider interests,” said Jack Hoadley, a research professor at Georgetown University. But the consumer often gets “stuck in the middle,” he told the forum in Tallahassee.

Florida has limited rules to protect consumers in HMOs against what is known as “balance billing,” but they don’t apply to other kinds of health plans, he noted. The state also has a dispute-resolution procedure, but it’s rarely used amid concerns including who pays for the process, a report by the Robert Wood Johnson Foundation found.

There’s generally no problem when a consumer knowingly chooses to pay more to see an out-of-network provider, officials said. But consumers often feel helpless and blindsided in emergency situations where they have no real choice, or when they choose in-network facilities only to be stunned by big bills from non-network providers there.

Some states such as Texas have required greater up-front transparency about charges. Maryland has tried to limit some charges to a percentage of what Medicare pays — say, 140 percent, Hoadley said. But medical providers contend such schemes often arbitrarily set prices too low, and Maryland excludes some big-ticket items such as air ambulance charges.

Industry groups have pointed plenty of fingers at one another. Insurers have shifted costs to patients through rising deductibles, co-pays and other means, said Jeff Scott, general counsel for the Florida Medical Association.

“These charges are surprises only to the uninformed patient,” Scott said.

Colorado, for instance, puts a greater burden on insurers to pay balance bills, Hoadley said.

But health plans say if out-of-network providers are allowed to charge whatever they like, it just leads to incentives to stay out of networks and send premiums rocketing for everyone.

“Some providers choose not to contract with health plans and, in fact, this is becoming a business model for some,” said Audrey Brown, president of the Florida Association of Health Plans.

James called the forum a successful first step to help legislators and regulators look for a solution.


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