Website article on lawsuits over hospital balance / surprise billing

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vmsx
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Website article on lawsuits over hospital balance / surprise billing

Post by vmsx » Thu Oct 11, 2018 8:35 pm

Since more and more people are being impacted by these events and for people who care about their finances:

https://www.mcall.com/opinion/yourview/ ... story.html

A bit more detail:
https://valawyersweekly.com/vamedicalla ... -hospital/

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 1:11 am

Interesting how they spin this as the hospital/provider's fault that insurance companies refuse to negotiate and only offer contracts of adhesion. If the insurance company offered competitive rates (like the other insurance companies they are in-network with) then everyone would sign up and this would not be an issue.

sawhorse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by sawhorse » Fri Oct 12, 2018 7:54 am

Thanks a lot for the links. Very interesting.

In my experience the opaque nature of medical costs extends far beyond the emergency room. Even for a simple lab test it's hard to find out the cost in advance.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by sawhorse » Fri Oct 12, 2018 8:28 am

toofache32 wrote:
Fri Oct 12, 2018 1:11 am
Interesting how they spin this as the hospital/provider's fault that insurance companies refuse to negotiate and only offer contracts of adhesion.
:confused I didn't get that impression.

Leesbro63
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by Leesbro63 » Fri Oct 12, 2018 8:36 am

From the artcle’s discussion of current lawsuits, it sounds like the issue of cash pricing is finally coming to a head.

staythecourse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by staythecourse » Fri Oct 12, 2018 9:23 am

Just for those who want to really understand the situation here it goes...

You have medical insurance which MAY not only restrict you access to in network physicians (those who signed a contract with your insurance if they do x they will get paid y for that service), but may allow OUT of network benefits. That means you can see ANY physician you want even those who have not signed a contract with your insurance to be paid y for x procedure like the in network doc.

When you get anything done you get the amount billed. That number does not matter. It is the ALLOWED amount that matters. That is the amount the contract between the provider and the insurance company says will pay y for x procedure.

The issue of the articles have to do with "balanced billing". That is a situation where the provider (hospital/ doctor/ surgery center) are OUT Of network for your insurance. If you have no out of network benefits you can't even see them if you wanted. IF you do have out of network benefits and see them the "balance" of what they bill and how much they get reimbursed by your insurance company (the allowed amont) as an out of network provider is billed to YOU.

Pretty shady and the reason is illegal for medicare patients and illegal in majority of states for commercial insurance. Best for all to check with their state laws concerning balanced billing. If there is an issue in your state simply get all your care at a major health system or university setting where they employ all their physicians to make sure everyone has the same contracts.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 12:31 pm

staythecourse wrote:
Fri Oct 12, 2018 9:23 am

If you have no out of network benefits you can't even see them if you wanted.
Huh? Anyone can see any doctor they want. My practice is completely out of network with all medical insurance and I am busy. I think you need to re-think this completely incorrect statement.

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JoMoney
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by JoMoney » Fri Oct 12, 2018 12:40 pm

article wrote:...Hospitals agree to accept the lowest amounts from Medicare and Medicaid...
Seems like I've seen that repeatedly. A few HMOs seem to negotiate better prices as well. I've heard good things about Kaiser. There's a fundamental problem with medical services not really being a "market". A fair market has competition, consumers have negotiating power, can substitute other products (or choose to go without). When a medical emergency arises individuals have no options.
"To achieve satisfactory investment results is easier than most people realize; to achieve superior results is harder than it looks." - Benjamin Graham

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 12:42 pm

staythecourse wrote:
Fri Oct 12, 2018 9:23 am

Pretty shady and the reason is illegal for medicare patients and illegal in majority of states for commercial insurance. Best for all to check with their state laws concerning balanced billing. If there is an issue in your state simply get all your care at a major health system or university setting where they employ all their physicians to make sure everyone has the same contracts.
Shady? Being forced to accept rates that are below cost for some services is shady?
What's shady is the insurance companies do not up their game and provide competitive fees. If the hospital did not sign up for their insurance, this means the insurance would not negotiate rates near what other insurances were offering. Again, this is an insurance problem. Do you really expect a hospital to work for free?

The other reason is the insurance company creates "narrow networks" which you need to google. This is where they purposefully only allow a minimum number of hospitals/providers in their network. This limits their liability to pay for services.

https://www.huffingtonpost.com/alex-tol ... 40820.html

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 12:45 pm

JoMoney wrote:
Fri Oct 12, 2018 12:40 pm
article wrote:...Hospitals agree to accept the lowest amounts from Medicare and Medicaid...
Seems like I've seen that repeatedly. A few HMOs seem to negotiate better prices as well. I've heard good things about Kaiser. There's a fundamental problem with medical services not really being a "market". A fair market has competition, consumers have negotiating power, can substitute other products (or choose to go without). When a medical emergency arises individuals have no options.
Hospitals like to be in-network with Medicare and Medicaid NOT because they are profitable, but because the hospitals can be eligible for additional government funding. Since the commercial insurance plans make up for the losses, this will not work if ALL the patients are government patients though.

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JoMoney
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by JoMoney » Fri Oct 12, 2018 12:59 pm

toofache32 wrote:
Fri Oct 12, 2018 12:45 pm
JoMoney wrote:
Fri Oct 12, 2018 12:40 pm
article wrote:...Hospitals agree to accept the lowest amounts from Medicare and Medicaid...
Seems like I've seen that repeatedly. A few HMOs seem to negotiate better prices as well. I've heard good things about Kaiser. There's a fundamental problem with medical services not really being a "market". A fair market has competition, consumers have negotiating power, can substitute other products (or choose to go without). When a medical emergency arises individuals have no options.
Hospitals like to be in-network with Medicare and Medicaid NOT because they are profitable, but because the hospitals can be eligible for additional government funding. Since the commercial insurance plans make up for the losses, this will not work if ALL the patients are government patients though.
Apparently though, not all the commercial insurers are willing to pay higher costs, 'out of network', etc.. either. Either way, individuals have no ability to negotiate and have to rely on a super organization that can and will say "no" to some price point. Unfortunately for those relying on private insurers they may not know their insurer isn't going to pay and get stuck with an unexpected liability.
There are some systems that seem to work with everyone being under a government umbrella at some level. Australia seems to have a good system where the public bears much of the risk/cost and government can attempt some level of price control, while at the same time having a private market for those who want and can afford a higher level of service, that's more affordable since everyone has the base emergency level coverage by the public "HMO".
"To achieve satisfactory investment results is easier than most people realize; to achieve superior results is harder than it looks." - Benjamin Graham

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 1:13 pm

JoMoney wrote:
Fri Oct 12, 2018 12:59 pm
toofache32 wrote:
Fri Oct 12, 2018 12:45 pm
JoMoney wrote:
Fri Oct 12, 2018 12:40 pm
article wrote:...Hospitals agree to accept the lowest amounts from Medicare and Medicaid...
Seems like I've seen that repeatedly. A few HMOs seem to negotiate better prices as well. I've heard good things about Kaiser. There's a fundamental problem with medical services not really being a "market". A fair market has competition, consumers have negotiating power, can substitute other products (or choose to go without). When a medical emergency arises individuals have no options.
Hospitals like to be in-network with Medicare and Medicaid NOT because they are profitable, but because the hospitals can be eligible for additional government funding. Since the commercial insurance plans make up for the losses, this will not work if ALL the patients are government patients though.
There are some systems that seem to work with everyone being under a government umbrella at some level. Australia seems to have a good system where the public bears much of the risk/cost and government can attempt some level of price control, while at the same time having a private market for those who want and can afford a higher level of service, that's more affordable since everyone has the base emergency level coverage by the public "HMO".
This is where we are headed...a 2-tiered health system. And there is nothing wrong with that.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by White Coat Investor » Fri Oct 12, 2018 1:20 pm

I purchased health care this week in an urgent situation. The practice does not accept any insurance. I was seen and taken care of. They told me it cost $532. I gave them my credit card and paid the bill and thanked the doctor for seeing me.

Medical care is expensive stuff. A lot of people wish it wasn't. But it is and always will be.

Realize that even if the situation were made perfect and efficient and transparent, that health care would still be expensive stuff. That's what happens with a business that is people intensive, the people are highly trained, there is significant liability, it is often provided 24/7/365, and the equipment is expensive.

I would have expected to have paid 3-4X that in an emergency department after hours.
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dm200
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 1:28 pm

For me, a real puzzle:

On the one hand, the US (compared to other countries) has a very large total medical care expenses per person, while on the other hand a great many providers claim health insurance, medicare, medicaid, etc. pay so little - that it is, allegedly, actually below their costs of providing the care.

I am so, so happy that my wife and I have both excellent healthcare coverage at relatively modest expenses (compared to many).

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JoMoney
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by JoMoney » Fri Oct 12, 2018 1:38 pm

dm200 wrote:
Fri Oct 12, 2018 1:28 pm
For me, a real puzzle:

On the one hand, the US (compared to other countries) has a very large total medical care expenses per person, while on the other hand a great many providers claim health insurance, medicare, medicaid, etc. pay so little - that it is, allegedly, actually below their costs of providing the care.

I am so, so happy that my wife and I have both excellent healthcare coverage at relatively modest expenses (compared to many).
It is a puzzle. I have to wonder why the only thing are system seems to be on top with is cost (and that's not a good thing). I wouldn't expect that everything would be perfect, I see the impossible trilema of not being able to (a) be the lowest cost , (b) provide the best outcomes , (c) cover the most people ... but if we aren't performing well along any of those lines I think the system needs major fixing.
"To achieve satisfactory investment results is easier than most people realize; to achieve superior results is harder than it looks." - Benjamin Graham

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dm200
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 1:45 pm

JoMoney wrote:
Fri Oct 12, 2018 1:38 pm
dm200 wrote:
Fri Oct 12, 2018 1:28 pm
For me, a real puzzle:
On the one hand, the US (compared to other countries) has a very large total medical care expenses per person, while on the other hand a great many providers claim health insurance, medicare, medicaid, etc. pay so little - that it is, allegedly, actually below their costs of providing the care.
I am so, so happy that my wife and I have both excellent healthcare coverage at relatively modest expenses (compared to many).
It is a puzzle. I have to wonder why the only thing are system seems to be on top with is cost (and that's not a good thing). I wouldn't expect that everything would be perfect, I see the impossible trilema of not being able to (a) be the lowest cost , (b) provide the best outcomes , (c) cover the most people ... but if we aren't performing well along any of those lines I think the system needs major fixing.
We cannot go very far there in this forum - but I am convinced politics is partly involved. Back when President Clinton tried to get healthcare changes, lots of politicians claimed that the healthcare system in the UK was terrible, and so on - I was employed by a company with employees around the world. I attended a two week training class at company headquarters in California - and there were three folks from the UK. Contrary to what so many US politicians claimed about how horrible things were in the UK -- all three of them expressed great happiness and satisfaction with their system.

staythecourse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by staythecourse » Fri Oct 12, 2018 1:48 pm

toofache32 wrote:
Fri Oct 12, 2018 12:31 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

If you have no out of network benefits you can't even see them if you wanted.
Huh? Anyone can see any doctor they want. My practice is completely out of network with all medical insurance and I am busy. I think you need to re-think this completely incorrect statement.
Man you don't know how insurance works. The PROVIDER can see anyone the want in network or out of network. The PATIENT'S insurance may NOT allow OON benefits for them to see you. That is the difference. If a pt. has x insurance and they have NO OON benefits then they have to pay the cash rate/ out of pocket charges to the providers office as the insurance company does not allow them to get covered through them to an OON doctor. If they do have OON benefits then they will have a different deductible and % coverage then then their in network benefits. You are seeing more insurance companies go with more narrow networks and eliminate OON benefits all together.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

staythecourse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by staythecourse » Fri Oct 12, 2018 1:51 pm

toofache32 wrote:
Fri Oct 12, 2018 12:42 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

Pretty shady and the reason is illegal for medicare patients and illegal in majority of states for commercial insurance. Best for all to check with their state laws concerning balanced billing. If there is an issue in your state simply get all your care at a major health system or university setting where they employ all their physicians to make sure everyone has the same contracts.
Shady? Being forced to accept rates that are below cost for some services is shady?
What's shady is the insurance companies do not up their game and provide competitive fees. If the hospital did not sign up for their insurance, this means the insurance would not negotiate rates near what other insurances were offering. Again, this is an insurance problem. Do you really expect a hospital to work for free?

The other reason is the insurance company creates "narrow networks" which you need to google. This is where they purposefully only allow a minimum number of hospitals/providers in their network. This limits their liability to pay for services.

https://www.huffingtonpost.com/alex-tol ... 40820.html
I'm sorry we just differ. It is fine to charge patients OON, but the issue is in balanced billing with multiple providers (ASC, surgeon, anesthesia, and path) how is a patient supposed to know everyone is an in network provider OR OON. Without having an easy way of knowing AND knowing the potential delta in charges ahead of time it is not reasonable to expect the patient just to pay whatever is put out AFTER the fact. Just doesn't seem fair to the consumer.

Good luck.
Last edited by staythecourse on Fri Oct 12, 2018 2:06 pm, edited 1 time in total.
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by sawhorse » Fri Oct 12, 2018 1:54 pm

White Coat Investor wrote:
Fri Oct 12, 2018 1:20 pm
I purchased health care this week in an urgent situation. The practice does not accept any insurance. I was seen and taken care of. They told me it cost $532. I gave them my credit card and paid the bill and thanked the doctor for seeing me.
How easy was it to get the price ahead of time? Was it a complex situation with multiple providers, tests, equipment, etc? In my experience if it's a simple office consultation with a single provider, it's relatively easy to get a price in advance. But once you add testing, equipment, procedures, multiple providers, etc then it becomes impossible.

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JoMoney
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by JoMoney » Fri Oct 12, 2018 1:58 pm

dm200 wrote:
Fri Oct 12, 2018 1:45 pm
...
We cannot go very far there in this forum - but I am convinced politics is partly involved. Back when President Clinton tried to get healthcare changes, lots of politicians claimed that the healthcare system in the UK was terrible, and so on - I was employed by a company with employees around the world. I attended a two week training class at company headquarters in California - and there were three folks from the UK. Contrary to what so many US politicians claimed about how horrible things were in the UK -- all three of them expressed great happiness and satisfaction with their system.
I've heard conflicting things from different people on whether or not they like their medical care, including in the U.S. from various HMOs (although I haven't heard anything first hand from someone not happy with Kaiser). I've heard people covered by the VA who literally believed the system was trying to kill them. I don't know what to make of the quality consideration, its the financial one that really hits home for me, and on that ground alone I'm not happy with the systems cost or with the options/coverage given to me even if I did use it.
"To achieve satisfactory investment results is easier than most people realize; to achieve superior results is harder than it looks." - Benjamin Graham

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:00 pm

dm200 wrote:
Fri Oct 12, 2018 1:28 pm
For me, a real puzzle:

On the one hand, the US (compared to other countries) has a very large total medical care expenses per person, while on the other hand a great many providers claim health insurance, medicare, medicaid, etc. pay so little - that it is, allegedly, actually below their costs of providing the care.
There is much more to the equation. On issue is a difference in expectations from the public. Another big problem in the US is all the administrators who provide no healthcare, but skim off of those providing the healthcare.

Image

sawhorse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by sawhorse » Fri Oct 12, 2018 2:03 pm

toofache32 wrote:
Fri Oct 12, 2018 2:00 pm
dm200 wrote:
Fri Oct 12, 2018 1:28 pm
For me, a real puzzle:

On the one hand, the US (compared to other countries) has a very large total medical care expenses per person, while on the other hand a great many providers claim health insurance, medicare, medicaid, etc. pay so little - that it is, allegedly, actually below their costs of providing the care.
There is much more to the equation. On issue is a difference in expectations from the public. Another big problem in the US is all the administrators who provide no healthcare, but skim off of those providing the healthcare.

Image
The same thing is happening in higher education. Faculty aren't making more. In fact they're making less as so many tenure track positions have been replaced with adjuncts who have no benefits and no job stability. Yet the administrative costs keep rising.

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:05 pm

staythecourse wrote:
Fri Oct 12, 2018 1:48 pm
toofache32 wrote:
Fri Oct 12, 2018 12:31 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

If you have no out of network benefits you can't even see them if you wanted.
Huh? Anyone can see any doctor they want. My practice is completely out of network with all medical insurance and I am busy. I think you need to re-think this completely incorrect statement.
Man you don't know how insurance works. The PROVIDER can see anyone the want in network or out of network. The PATIENT'S insurance may NOT allow OON benefits for them to see you. That is the difference. If a pt. has x insurance and they have NO OON benefits then they have to pay the cash rate/ out of pocket charges to the providers office as the insurance company does not allow them to get covered through them to an OON doctor. If they do have OON benefits then they will have a different deductible and % coverage then then their in network benefits. You are seeing more insurance companies go with more narrow networks and eliminate OON benefits all together.

Good luck.
I know exactly how insurance works. That's how I am able to survive out of network. I have no reason to be in-network. You stated patients without OON benefits cannot see an OON doctor even if they wanted to. I am saying that they CAN see the doctor, but they have to pay themselves. The same way they pay for other goods and services in their daily lives. Do you have grocery insurance? No?? Then how do you eat??

OON benefits are almost completely non-existant.

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dm200
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 2:09 pm

JoMoney wrote:
Fri Oct 12, 2018 1:58 pm
dm200 wrote:
Fri Oct 12, 2018 1:45 pm
...
We cannot go very far there in this forum - but I am convinced politics is partly involved. Back when President Clinton tried to get healthcare changes, lots of politicians claimed that the healthcare system in the UK was terrible, and so on - I was employed by a company with employees around the world. I attended a two week training class at company headquarters in California - and there were three folks from the UK. Contrary to what so many US politicians claimed about how horrible things were in the UK -- all three of them expressed great happiness and satisfaction with their system.
I've heard conflicting things from different people on whether or not they like their medical care, including in the U.S. from various HMOs (although I haven't heard anything first hand from someone not happy with Kaiser). I've heard people covered by the VA who literally believed the system was trying to kill them. I don't know what to make of the quality consideration, its the financial one that really hits home for me, and on that ground alone I'm not happy with the systems cost or with the options/coverage given to me even if I did use it.
Yes - very happy with Kaiser - BOTH high quality and relatively low cost. In my opinion, the folks I know who have been unhappy with Kaiser seem to be folks who have not learned to use the features of Kaiser (many not even tries).

staythecourse
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by staythecourse » Fri Oct 12, 2018 2:10 pm

toofache32 wrote:
Fri Oct 12, 2018 2:05 pm
staythecourse wrote:
Fri Oct 12, 2018 1:48 pm
toofache32 wrote:
Fri Oct 12, 2018 12:31 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

If you have no out of network benefits you can't even see them if you wanted.
Huh? Anyone can see any doctor they want. My practice is completely out of network with all medical insurance and I am busy. I think you need to re-think this completely incorrect statement.
Man you don't know how insurance works. The PROVIDER can see anyone the want in network or out of network. The PATIENT'S insurance may NOT allow OON benefits for them to see you. That is the difference. If a pt. has x insurance and they have NO OON benefits then they have to pay the cash rate/ out of pocket charges to the providers office as the insurance company does not allow them to get covered through them to an OON doctor. If they do have OON benefits then they will have a different deductible and % coverage then then their in network benefits. You are seeing more insurance companies go with more narrow networks and eliminate OON benefits all together.

Good luck.
I know exactly how insurance works. That's how I am able to survive out of network. I have no reason to be in-network. You stated patients without OON benefits cannot see an OON doctor even if they wanted to. I am saying that they CAN see the doctor, but they have to pay themselves. The same way they pay for other goods and services in their daily lives. Do you have grocery insurance? No?? Then how do you eat??

OON benefits are almost completely non-existant.
That is EXACTLY what I said above. IF the patient insurance does not allow OON benefits then they have to pay to see that doctor as a cash pay/ out of pocket rate.

You are wrong. I have MANY folks I see OON. IT is very geographical if commercial insurances allow OON or not. You would know that if you knew as much about insurance as you state.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:11 pm

staythecourse wrote:
Fri Oct 12, 2018 1:51 pm
toofache32 wrote:
Fri Oct 12, 2018 12:42 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

Pretty shady and the reason is illegal for medicare patients and illegal in majority of states for commercial insurance. Best for all to check with their state laws concerning balanced billing. If there is an issue in your state simply get all your care at a major health system or university setting where they employ all their physicians to make sure everyone has the same contracts.
Shady? Being forced to accept rates that are below cost for some services is shady?
What's shady is the insurance companies do not up their game and provide competitive fees. If the hospital did not sign up for their insurance, this means the insurance would not negotiate rates near what other insurances were offering. Again, this is an insurance problem. Do you really expect a hospital to work for free?

The other reason is the insurance company creates "narrow networks" which you need to google. This is where they purposefully only allow a minimum number of hospitals/providers in their network. This limits their liability to pay for services.

https://www.huffingtonpost.com/alex-tol ... 40820.html
I'm sorry we just differ. Just because I am a physician and would make money out of it doesn't make the process right. It doesn't matter what you think the government thinks balanced billing is wrong as well as it illegal. Simple as that.

Good luck.
Well it's obviously not "simple as that" although a simple mind who refuses to evaluate all sides will think so. Your beloved government price controls are already driving providers away from offering their services in these situations. I am one of them. I no longer take call at my local hospital. Why? Because I would get up in the middle of the night and drive in to see a patient for a consultation. Insurance paid me $80. Not even close to worth it. I know women who pay that for their hair every month.

Good luck.

toofache32
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:15 pm

staythecourse wrote:
Fri Oct 12, 2018 2:10 pm
toofache32 wrote:
Fri Oct 12, 2018 2:05 pm
staythecourse wrote:
Fri Oct 12, 2018 1:48 pm
toofache32 wrote:
Fri Oct 12, 2018 12:31 pm
staythecourse wrote:
Fri Oct 12, 2018 9:23 am

If you have no out of network benefits you can't even see them if you wanted.
Huh? Anyone can see any doctor they want. My practice is completely out of network with all medical insurance and I am busy. I think you need to re-think this completely incorrect statement.
Man you don't know how insurance works. The PROVIDER can see anyone the want in network or out of network. The PATIENT'S insurance may NOT allow OON benefits for them to see you. That is the difference. If a pt. has x insurance and they have NO OON benefits then they have to pay the cash rate/ out of pocket charges to the providers office as the insurance company does not allow them to get covered through them to an OON doctor. If they do have OON benefits then they will have a different deductible and % coverage then then their in network benefits. You are seeing more insurance companies go with more narrow networks and eliminate OON benefits all together.

Good luck.
I know exactly how insurance works. That's how I am able to survive out of network. I have no reason to be in-network. You stated patients without OON benefits cannot see an OON doctor even if they wanted to. I am saying that they CAN see the doctor, but they have to pay themselves. The same way they pay for other goods and services in their daily lives. Do you have grocery insurance? No?? Then how do you eat??

OON benefits are almost completely non-existant.
That is EXACTLY what I said above. IF the patient insurance does not allow OON benefits then they have to pay to see that doctor as a cash pay/ out of pocket rate.

You are wrong. I have MANY folks I see OON. IT is very geographical if commercial insurances allow OON or not. You would know that if you knew as much about insurance as you state.

Good luck.
The beauty of OON is that it does not involve insurance and has nothing to do with insurance. I provide a cost which the patient pays. Very simple. You were saying the patient could not SEE an OON doctor without OON benefits. I am saying that patients are not limited by their insurance and can pay cash just like thousands of patients do every day. The patient (NOT the insurance as you suggest) gets to decide if this is worth it or not to pay their own money. So simple.

Good luck.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:19 pm

If a hospital is OON and they should just accept whatever insurance feels like they are worth, how does the hospital know if that payment is in line with what that insurance pays other hospitals? If the payments were not high enough to be acceptable during negotiations, why should the hospital be forced to accept that amount? This is mob-rule.
Last edited by toofache32 on Fri Oct 12, 2018 2:22 pm, edited 2 times in total.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 2:21 pm

The beauty of OON is that it does not involve insurance and has nothing to do with insurance. I provide a cost which the patient pays. Very simple. You were saying the patient could not SEE an OON doctor without OON benefits. I am saying that patients are not limited by their insurance and can pay cash just like thousands of patients do every day. The patient (NOT the insurance as you suggest) gets to decide if this is worth it or not to pay their own money. So simple.
True. The patient, then, is paying for an insurance "benefit" without getting that "benefit" in full.

No expert, but I tend to believe that the benefits of seeing an out of network provider are often overstated by patients. Just my non-medical opinion.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 2:24 pm

toofache32 wrote:
Fri Oct 12, 2018 2:19 pm
If a hospital is OON and they should just accept whatever insurance feels like they are worth, how does the hospital know if that payment is in line with what that insurance pays other hospitals? If the payments were not high enough to be acceptable during negotiations, why should the hospital be forced to accept that amount?
Several years ago, my plan eliminated a very large area hospital from any services (except the Emergency department) and beefed up their presence and services at other hospitals. As long as I can go to a competent hospital when I need one (as my wife did two years ago), I am just as happy.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:24 pm

dm200 wrote:
Fri Oct 12, 2018 2:21 pm
The beauty of OON is that it does not involve insurance and has nothing to do with insurance. I provide a cost which the patient pays. Very simple. You were saying the patient could not SEE an OON doctor without OON benefits. I am saying that patients are not limited by their insurance and can pay cash just like thousands of patients do every day. The patient (NOT the insurance as you suggest) gets to decide if this is worth it or not to pay their own money. So simple.
True. The patient, then, is paying for an insurance "benefit" without getting that "benefit" in full.

No expert, but I tend to believe that the benefits of seeing an out of network provider are often overstated by patients. Just my non-medical opinion.
Very true and it greatly depends on the problem being treated, the specialty/facility involved, and the in-network options available.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:29 pm

dm200 wrote:
Fri Oct 12, 2018 2:24 pm
toofache32 wrote:
Fri Oct 12, 2018 2:19 pm
If a hospital is OON and they should just accept whatever insurance feels like they are worth, how does the hospital know if that payment is in line with what that insurance pays other hospitals? If the payments were not high enough to be acceptable during negotiations, why should the hospital be forced to accept that amount?
Several years ago, my plan eliminated a very large area hospital from any services (except the Emergency department) and beefed up their presence and services at other hospitals. As long as I can go to a competent hospital when I need one (as my wife did two years ago), I am just as happy.
Most healthcare consumers are not as tuned in to their insurance as you. Most people have no idea which local hospitals are in their network. My question was referring to when a patient shows up to an OON hospital. The hospital is required by law to evaluate the patient and cannot turn them away if there is an emergency. This is an unfunded mandate and now those hospitals are being told they cannot bill for these services at all if insurance doesn't pay?
Last edited by toofache32 on Fri Oct 12, 2018 2:38 pm, edited 1 time in total.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 2:36 pm

sorry duplicate post

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by White Coat Investor » Fri Oct 12, 2018 2:40 pm

sawhorse wrote:
Fri Oct 12, 2018 1:54 pm
White Coat Investor wrote:
Fri Oct 12, 2018 1:20 pm
I purchased health care this week in an urgent situation. The practice does not accept any insurance. I was seen and taken care of. They told me it cost $532. I gave them my credit card and paid the bill and thanked the doctor for seeing me.
How easy was it to get the price ahead of time? Was it a complex situation with multiple providers, tests, equipment, etc? In my experience if it's a simple office consultation with a single provider, it's relatively easy to get a price in advance. But once you add testing, equipment, procedures, multiple providers, etc then it becomes impossible.
They gave me the office visit ($192) price up front, but noted it didn't include procedures, which I knew I needed. I guess I could have asked about it and they could have told me because they told me at the end of the visit.

But I didn't feel like shopping it around to the two other urgent cares in the area to save a few bucks. I wanted to get it done and get back to my vacation. Too bad I wasn't home where I could have been seen by my partners or with my usual rather extensive first aid kit or I would have walked my wife through the procedure.
Last edited by White Coat Investor on Fri Oct 12, 2018 2:41 pm, edited 1 time in total.
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 2:40 pm

Most healthcare consumers are not as tuned in to their insurance as you. Most people have no idea which local hospitals are in their network. My question was referring to when a patient shows up to an OON hospital. The hospital is required by law to evaluate the patient and cannot turn them away if there is an emergency. This is an unfunded mandate.
True. Sometimes I feel like a driver following the signs on a one-way street -- while lots of other drivers are all going the wrong way - and are angry at me!!

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by brcarls » Fri Oct 12, 2018 2:46 pm

The incident I had was when I went in for a fairly simple procedure (ESI) which I could plan and negotiate ahead of time.

I had in-network neurologists and neurosurgeon and had it done at an in-network hospital. I made it clear to everyone involved that I did not consent to care from anyone out of network and even made a note to that effect on the contract with the hospital when I pre-paid for everything. I even got a list of everyone who would be in the OR and vetted them with my insurance company.

Then, 6 months after the procedure, I get a huuuge bill from some out of network anesthesiologist who I had never heard of. The hospital said "oh, the one scheduled for your procedure had a conflict, so we substituted the only one who was available".

I just said "Too bad, I'm not paying, see you in court", but it's been a couple of years now and so far I have heard nothing further about it.... In my opinion, it was criminal behavior and someone should go to jail for trying to pull a scam like that. Other than several orders of magnitude, that anesthesiologist was no different than the scum who throw crap on your windshield and then squeegee it off expecting to be paid for the work they performed. In a just world, they would be removed from civil society.
Last edited by brcarls on Fri Oct 12, 2018 2:49 pm, edited 1 time in total.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by Kennedy » Fri Oct 12, 2018 2:48 pm

Part of the problem is that in a hospital situation, the patient is not clearly and specifically told in advance by a prospective provider that they are out-of-network and that the patient may end up paying a whopping amount of money as part of balance billing. Sure, the patient will be required to sign a payment accepting financial responsibility, but the information is rarely communicated in a way to cause the light bulb to go off in the patient's head to trigger him to ask if there is another option for providers.

In our case, we had a family member admitted to an in-network hospital. They later required transfer to another in-network hospital for a higher level of care. Hospital number one called an ambulance for the transport. It never occurred to us that the ambulance called to transfer between two in-network hospitals could be out-of-network. We found out the ambulance's status a month later when balanced billed.

We went round and round with the insurance company and the ambulance company. The insurance company used third party data to pay the amount they considered fair. Of course, the ambulance company disagreed and wouldn't budge from its initial billed amount. We paid. Lots of money. The lack of clear and specific disclosure was unfair. Had we known, we would have called the insurance company to find out which ambulance company was in-network. (It wasn't an urgent situation.) We know better now.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by Broken Man 1999 » Fri Oct 12, 2018 2:55 pm

Wife and I have a PPO plan that costs $630/year more than the virtually identical HM0.

Fact is, after several years, I have never had to go out of network.

Probably a waste of money but you never know what might happen.


So there is a way to have a larger network, but it does cost. And you still have to find a provider that takes your insurance.

Broken Man 1999

PS: Insurance should have to pay the charges for out of network if they haven't secured a!l the services their policyholders need.

Instead, they leave customers uncovered.
“If I cannot drink Bourbon and smoke cigars in Heaven than I shall not go. " -Mark Twain

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dm200
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 2:56 pm

This dates me, but unfortunately, often very "accurate": https://www.youtube.com/watch?v=yYtfejT4QgM

GaryEsq
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Re: Website article on lawsuits over hospital balance / surprise billing

Post by GaryEsq » Fri Oct 12, 2018 3:12 pm

Since more and more people are being impacted by these events and for people who care about their finances:

https://www.mcall.com/opinion/yourview/ ... story.html

A bit more detail:
https://valawyersweekly.com/vamedicalla ... -hospital/
Interesting position that the court took in this matter. However, on appeal The Supreme Court in Virginia overturned the lower court's decision, finding that contrary to the circuit court's ruling, the evidence established that the plaintiff/appellee agreed to the terms of the contract. The case was remanded back to the circuit court for further proceedings consistent with the appellate court's decision.

http://www.courts.state.va.us/courts/sc ... 161019.pdf
Last edited by GaryEsq on Fri Oct 12, 2018 3:17 pm, edited 2 times in total.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by NoviceMD » Fri Oct 12, 2018 3:14 pm

brcarls wrote:
Fri Oct 12, 2018 2:46 pm
The incident I had was when I went in for a fairly simple procedure (ESI) which I could plan and negotiate ahead of time.

I had in-network neurologists and neurosurgeon and had it done at an in-network hospital. I made it clear to everyone involved that I did not consent to care from anyone out of network and even made a note to that effect on the contract with the hospital when I pre-paid for everything. I even got a list of everyone who would be in the OR and vetted them with my insurance company.

Then, 6 months after the procedure, I get a huuuge bill from some out of network anesthesiologist who I had never heard of. The hospital said "oh, the one scheduled for your procedure had a conflict, so we substituted the only one who was available".

I just said "Too bad, I'm not paying, see you in court", but it's been a couple of years now and so far I have heard nothing further about it.... In my opinion, it was criminal behavior and someone should go to jail for trying to pull a scam like that. Other than several orders of magnitude, that anesthesiologist was no different than the scum who throw crap on your windshield and then squeegee it off expecting to be paid for the work they performed. In a just world, they would be removed from civil society.



I hate to break it to you, but it has nothing to do with the anesthesiologist. He/She just showed up for work that day. Anesthesiologists work for hospitals or private groups that have a million different contracts with a million different insurance companies which each have a million different plans. They have no way of knowing case by case, and don’t have the ability to remove themselves from that case if not in your network. So while your frustration is understandable and the insurance business/health care is a mess, it is misguided. The anesthesiologist was just called in to cover a case for someone who was unavailable. The issue lies with the hospital and near criminal behavior by many insurance companies. They just do a better job than doctors of twisting the narrative and diverting blame.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 3:16 pm

White Coat Investor wrote:
Fri Oct 12, 2018 2:40 pm
sawhorse wrote:
Fri Oct 12, 2018 1:54 pm
White Coat Investor wrote:
Fri Oct 12, 2018 1:20 pm
I purchased health care this week in an urgent situation. The practice does not accept any insurance. I was seen and taken care of. They told me it cost $532. I gave them my credit card and paid the bill and thanked the doctor for seeing me.
How easy was it to get the price ahead of time? Was it a complex situation with multiple providers, tests, equipment, etc? In my experience if it's a simple office consultation with a single provider, it's relatively easy to get a price in advance. But once you add testing, equipment, procedures, multiple providers, etc then it becomes impossible.
They gave me the office visit ($192) price up front, but noted it didn't include procedures, which I knew I needed. I guess I could have asked about it and they could have told me because they told me at the end of the visit.

But I didn't feel like shopping it around to the two other urgent cares in the area to save a few bucks. I wanted to get it done and get back to my vacation. Too bad I wasn't home where I could have been seen by my partners or with my usual rather extensive first aid kit or I would have walked my wife through the procedure.
That's how my office works. Patients are given a fee up front for the office consult ($235) which includes any and all xrays which are sometimes needed. Many patients end up needing an office procedure such as a biopsy. They are quoted a fee for this also (about $500 or about $1000 if more complex). If you do the procedure on the same day, then I only charge for the procedure so you save the $235. Patients seem to really appreciate how fees are known up front and we NEVER ask for more money later. Back when I was in-network with insurance, I was not able to give true fees up front, only estimates based on inaccurate insurance info which was often wrong. People complain about lack of price transparency and don't realize this is an INSURANCE phenomenon.
Last edited by toofache32 on Fri Oct 12, 2018 3:18 pm, edited 1 time in total.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 3:17 pm

I hate to break it to you, but it has nothing to do with the anesthesiologist. He/She just showed up for work that day. Anesthesiologists work for hospitals or private groups that have a million different contracts with a million different insurance companies which each have a million different plans. They have no way of knowing case by case, and don’t have the ability to remove themselves from that case if not in your network. So while your frustration is understandable and the insurance business/health care is a mess, it is misguided. The anesthesiologist was just called in to cover a case for someone who was unavailable. The issue lies with the hospital and near criminal behavior by many insurance companies. They just do a better job than doctors of twisting the narrative and diverting blame.
It seems to me that the insurance company chose to take the risk of not having the required providers for the service.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 3:23 pm

Broken Man 1999 wrote:
Fri Oct 12, 2018 2:55 pm

PS: Insurance should have to pay the charges for out of network if they haven't secured a!l the services their policyholders need.

Instead, they leave customers uncovered.
THIS! If the insurance refuses to negotiate acceptable fees then they shouldn't get to just walk away from it. As it stands now, the insurance company ALWAYS wins. They get your premiums and they don't have to pay out claims.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by dm200 » Fri Oct 12, 2018 3:25 pm

toofache32 wrote:
Fri Oct 12, 2018 3:23 pm
Broken Man 1999 wrote:
Fri Oct 12, 2018 2:55 pm

PS: Insurance should have to pay the charges for out of network if they haven't secured a!l the services their policyholders need.

Instead, they leave customers uncovered.
THIS! If the insurance refuses to negotiate acceptable fees then they shouldn't get to just walk away from it. As it stands now, the insurance company ALWAYS wins. They get your premiums and they don't have to pay out claims.
Right. They seem to be selling something where they cannot always deliver.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by sawhorse » Fri Oct 12, 2018 3:26 pm

NoviceMD wrote:
Fri Oct 12, 2018 3:14 pm
I hate to break it to you, but it has nothing to do with the anesthesiologist. He/She just showed up for work that day. Anesthesiologists work for hospitals or private groups that have a million different contracts with a million different insurance companies which each have a million different plans. They have no way of knowing case by case, and don’t have the ability to remove themselves from that case if not in your network. So while your frustration is understandable and the insurance business/health care is a mess, it is misguided. The anesthesiologist was just called in to cover a case for someone who was unavailable. The issue lies with the hospital and near criminal behavior by many insurance companies. They just do a better job than doctors of twisting the narrative and diverting blame.
At least some anesthesiologists, particularly those in private groups, have the ability to set their list price that patients without insurance coverage, or with an insurance they don't take, are charged.

If they are on salary at the hospital, that might be different. And if they are junior in their physician group, they might not get a say either.

Emergency physician groups are doing something similar to patients.

https://www.nytimes.com/2017/07/24/upsh ... bills.html

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by toofache32 » Fri Oct 12, 2018 3:29 pm

NoviceMD wrote:
Fri Oct 12, 2018 3:14 pm
brcarls wrote:
Fri Oct 12, 2018 2:46 pm
The incident I had was when I went in for a fairly simple procedure (ESI) which I could plan and negotiate ahead of time.

I had in-network neurologists and neurosurgeon and had it done at an in-network hospital. I made it clear to everyone involved that I did not consent to care from anyone out of network and even made a note to that effect on the contract with the hospital when I pre-paid for everything. I even got a list of everyone who would be in the OR and vetted them with my insurance company.

Then, 6 months after the procedure, I get a huuuge bill from some out of network anesthesiologist who I had never heard of. The hospital said "oh, the one scheduled for your procedure had a conflict, so we substituted the only one who was available".

I just said "Too bad, I'm not paying, see you in court", but it's been a couple of years now and so far I have heard nothing further about it.... In my opinion, it was criminal behavior and someone should go to jail for trying to pull a scam like that. Other than several orders of magnitude, that anesthesiologist was no different than the scum who throw crap on your windshield and then squeegee it off expecting to be paid for the work they performed. In a just world, they would be removed from civil society.



I hate to break it to you, but it has nothing to do with the anesthesiologist. He/She just showed up for work that day. Anesthesiologists work for hospitals or private groups that have a million different contracts with a million different insurance companies which each have a million different plans. They have no way of knowing case by case, and don’t have the ability to remove themselves from that case if not in your network. So while your frustration is understandable and the insurance business/health care is a mess, it is misguided. The anesthesiologist was just called in to cover a case for someone who was unavailable. The issue lies with the hospital and near criminal behavior by many insurance companies. They just do a better job than doctors of twisting the narrative and diverting blame.
Completely agree there is little understanding of how things work in that post. If they simply cancelled his surgery at the last minute since that special anesthesiologist was not available, he would be here complaining "I took a day off work and they didn't do my surgery so they need to pay me for a day of lost wages." Can't please everyone.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by tj » Fri Oct 12, 2018 3:43 pm

toofache32 wrote:
Fri Oct 12, 2018 3:23 pm
Broken Man 1999 wrote:
Fri Oct 12, 2018 2:55 pm

PS: Insurance should have to pay the charges for out of network if they haven't secured a!l the services their policyholders need.

Instead, they leave customers uncovered.
THIS! If the insurance refuses to negotiate acceptable fees then they shouldn't get to just walk away from it. As it stands now, the insurance company ALWAYS wins. They get your premiums and they don't have to pay out claims.

Can't you purchase an insurance policy that has a larger network?

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by brcarls » Fri Oct 12, 2018 4:01 pm

toofache32 wrote:
Fri Oct 12, 2018 3:29 pm
Completely agree there is little understanding of how things work in that post. If they simply cancelled his surgery at the last minute since that special anesthesiologist was not available, he would be here complaining "I took a day off work and they didn't do my surgery so they need to pay me for a day of lost wages." Can't please everyone.
Not even close. If they had informed me that the anesthesiologist was out of network, I would have walked out of pre-op. I would have had to pop Vicodin like candy for another month while I sought care elsewhere, but that's better than risking financial ruin.

They tried to take advantage of me while I was at my most vulnerable, despite assuring me 2 hours before the procedure that there would be no financial surprises. I even made the clueless admin, who took my pre-payment in full, initial on the contract where I wrote in that I did not consent to care from out of network providers.... but they did not care and did it anyway. That is not on the insurance company, that is on the unethical doctors and administrators who deliberately chose to prey on me.

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Re: Website article on lawsuits over hospital balance / surprise billing

Post by JoMoney » Fri Oct 12, 2018 4:07 pm

tj wrote:
Fri Oct 12, 2018 3:43 pm
toofache32 wrote:
Fri Oct 12, 2018 3:23 pm
Broken Man 1999 wrote:
Fri Oct 12, 2018 2:55 pm

PS: Insurance should have to pay the charges for out of network if they haven't secured a!l the services their policyholders need.

Instead, they leave customers uncovered.
THIS! If the insurance refuses to negotiate acceptable fees then they shouldn't get to just walk away from it. As it stands now, the insurance company ALWAYS wins. They get your premiums and they don't have to pay out claims.

Can't you purchase an insurance policy that has a larger network?
Many (maybe most) don't fully understand the nuances of their coverage. Costs are extremely prohibitive, especially when considering that choosing some other option may be giving up an employer subsidy for whatever options employer plans provide.
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