Surprise Out-of-Network Medical Bills at Glen Rose Medical Center - 2019
9 May 2019 at 2:19:23 PM
Interesting report from Center for Public Policy Priorities. Basically, suppose you go to Glen Rose Medical Center in an emergency situation. The chances are that the doctor or staff that treats you may be part of an out-of-network insurance network and thus, you may find yourself paying "surprise" or higher bills.
Even diligent patients who ask all of the right questions can get hit with surprise, out-of-network medical bills. This is especially likely to happen in an emergency, when sick or injured Texans must rush to the nearest emergency room and have no ability to choose the doctors who treat them or confirm they are part of their insurance network.
Surprise out-of-network medical bills, sometimes called “balance bills,” happen when insurers and doctors fighting over prices jointly pass the buck to a patient who received out-of-network care unknowingly. The Texas Legislature, long frustrated by this practice, developed a mediation system for surprise bills in 2009 and improved the system in 2015. When patients are able to access the system, it works well. Disputes are almost always resolved with a phone call between the doctor’s office and insurer, with actual mediation rarely needed.
Unfortunately, very few Texas patients have managed to access the system – only 3,824 since 2009. We estimate that 250,000 Texans who have a mediation-eligible health plan will get a surprise, out-of-network medical bill in a two-year period. In other words, only a very small fraction of Texans with surprise bills get help.
Here's a video from the Somervell County Hospital District meeting of August 30, 2018 in which Emcare is discussed.
More from the original link
When patients get out-of-network care unknowingly In emergencies Most Texans will end up in an emergency room at some point, and when there, will generally have no ability to ensure their care is in-network. In an emergency, patients often lack the time or ability to determine if a hospital is in-network. Also, in emergencies, patients generally get no choice in providers. Patients don’t get to pick what ambulance shows up when they call 9-1-1, which ER the ambulance goes to, or which doctor at the ER provides care. 4 ER trips generally result in at least two medical bills—one from the facility (hospital or free-standing ER) and another from physician(s) who provided treatment (such as emergency room physicians and radiologists). Patients may unknowingly get care in an out-of-network facility, if for example, the closest ER that a patient is rushed to does not participate in the patient’s insurance network.
In these cases, patients may get a surprise bill from the facility. In other cases, patients in an emergency will get to an in-network hospital, but still receive out-of-network care. Patients have a reasonable expectation that if they go to an in-network hospital, all of their care within the hospital will also be in-network. But most patients don’t know that, in many cases, the doctors who practice at a hospital are not employees of the hospital. Hospitals and other facilities commonly contract with groups of doctors or individual physicians to provide services like anesthesiology, emergency department physician services, neonatology, pathology, and radiology. These contracted doctors do not necessarily participate in the same insurance plans as the hospital. In fact, for some specialties like emergency room physicians and anesthesiologists, it is relatively common for doctors to be out-of-network even though the hospital is in-network (see Figure 2). In these cases, patients may get a surprise bill from one or more doctors.
Going to an in-network hospital and leaving with out-of-network bills is understandably surprising and frustrating for patients. Hospital-based care is delivered and billed for under a different model than most consumer services. Imagine going out to eat and receiving unexpected bills from the host, waiter, cook, and dishwasher, some of whom were willing to negotiate discounts or accept coupons, while others were not. This is essentially what happens at a hospital. Even though the care is provided under one roof, the insurance network arrangements and billing are separate for many services.
On page 14, there is a chart of Texas hospitals where surprise emergency billing appears rare. Lake Granbury Medical Center, for example, is in that category. On page 16 is a chart for Hospitals where surprise emergency billing appears nearly guaranteed (percentage of out-of-network ER doctor billing of 95% or more) Glen Rose Medical Center is on that list.
Here are a few suggestions for fixing this, from the report
Ultimately, the best and most complete solution for patients that builds off of our existing surprise bill mediation system would incorporate the following principles: