It can be the most unpleasant of surprises at a time a patient is still recovering from a recent surgery: A bill for hundreds, if not thousands, of dollars for medical services shows up — services that the patient believed were covered by insurance.
In one scenario, the hospital and surgeon are in-network but, unknown to the patient, the anesthesiologist or radiologist or other specialist is not. So when the insurer balks at paying the claim at out-of-network rates, the balance of the bill lands in the patient’s mailbox.
“It is happening across the state, and we’ve had enough complaints that it’s caught the commissioner’s attention,” said Ronald Ruman, state Insurance Department spokesman. On Thursday, Insurance Commissioner Teresa Miller will hold a public informational hearing in Harrisburg on what the department terms “surprise” balance billing.
“It is critical that we address this issue in order to protect consumers from getting an unexpected bill from a provider,” said Ms. Miller in a release.
“When someone faces a health issue such as surgery, treatment in an emergency room, or even a routine procedure, they should be free from worrying about facing financial hardship once they return home.”
A March online survey of more than 2,000 consumers by the Consumer Reports National Research Center found 37 percent reported receiving a “surprise” medical bill, where the plan paid less than was expected, while 25 percent of those surprises involved bills from a doctor they did not expect to be billed by.
Historically, Western Pennsylvania residents have not had to worry too much about networks in which patients pay negotiated discounted fees for providers and facilities. But between Pittsburgh health giants Highmark and UPMC going their separate ways this year after insurer Highmark created its own provider network to compete with UPMC’s health system and the emergence of narrower and “tiered” networks, the dynamics have changed.
Mr. Ruman cited two recent complaint examples originating in Western Pennsylvania: In one instance, a patient scheduled a stress test with an in-network physician. The cardiologist who evaluated the test result, however, was out of network and balance-billed the patient.
In another case, a patient underwent a colonoscopy using an in-network physician but did not know the anesthesiologist was out of network.
“The consumer also claims he had no knowledge of a problem for nearly two years, as he says the provider had tried to contact the consumer’s insurer for payment, then sent the balance bill to the consumer,” the complaint stated.
“The consumer appealed to his insurer, but the appeal was denied because it came after the 180-day appeal period, even though the consumer maintains he had no idea an appeal was needed until well past this deadline.”
While the amounts billed to patients can vary widely, depending on the service provided and the patient’s insurance plan, “we have seen balance bills in the hundreds, and even thousands, of dollars,” Mr. Ruman said.
A year ago, with the imminent end of the UPMC-Highmark contract looming, both the Hospital Council of Western Pennsylvania and the Allegheny County Medical Society suggested the creation of an ombudsman hotline so physicians and patients would know if they face a greater-than-expected bill.
Some states have moved to block providers from charging more than in-network rates.
Pennsylvania is not there yet, but the insurance department has called Thursday’s hearing “an opportunity to begin exploring options to make sure consumers are informed about their care and do not face these unexpected bills without recourse.”
Mr. Ruman said testimony from consumers is expected, as well as from insurers and health care providers.
The hearing is scheduled to run from 10 a.m. to 1 p.m. in the auditorium of the State Museum, 300 N. St. in Harrisburg and will be live-streamed at http://pacast.com/players/live_insurance.asp.