Currently Viewing:
In Focus Blog
Currently Reading
Consumers Making Good-Faith Efforts to Honor Networks May Find Relief From Surprise Bills
August 19, 2015 – Mary K. Caffrey
Challenges Await as Medicaid Managed Care Absorbs the Most Fragile Patients
August 17, 2015 – Mary K. Caffrey
Kasich's Use of Managed Care Tools Cited in Medicaid Savings
August 14, 2015 – Mary K. Caffrey
HHS Finds Competition Helped Consumers Under ACA, But Will It Be Short-Lived?
July 31, 2015 – Mary K. Caffrey
Over 50 Years, Medicare and Medicaid Evolve, With a Greater Role for Managed Care
July 30, 2015 – Mary K. Caffrey
California Exchange Reports Average Premium Hike of 4%
July 28, 2015 – Mary K. Caffrey
Will Drug Costs Be the Big Political Issue of 2016?
July 24, 2015 – Mary K. Caffrey
States That Expanded Medicaid Under ACA Find More Sign Up Than Planned
July 20, 2015 – Mary K. Caffrey
Senate Panel Takes Aim at Dietary Recommendations in Funding Bill
July 15, 2015 – Mary K. Caffrey

Consumers Making Good-Faith Efforts to Honor Networks May Find Relief From Surprise Bills

Mary K. Caffrey
New York has a new law to protect consumers, and New Jersey and California are weighing similar legislation.
The horror stories have come in from all over the country: the New Jersey teenager hurt in a skiing accident whose parents drove him hours to their in-network hospital, only to be hit by giant bills from an out-of-network surgeon.

A Pennsylvania couple showed up at the emergency room when the husband, in this 50s, was feeling out of sorts and suspected pneumonia. It turned out he needed open heart surgery—immediately. The couple was careful to transfer to a larger hospital that took the wife’s insurance plan. But that didn’t matter when the heart surgeon turned out to be out-of-network. The bills started showing up when her husband was is rehab.

The rise of narrow networks in managed care has put patients in the middle. Doctors and hospitals say they feel badly about it, and a commentary in JAMA Surgery even said hospitals should be compelled to address it. But these days it’s state legislators that are doing the heavy lifting, as constituents flood their inboxes with tales of five-figure bills they can’t pay. Many cases involve emergencies, as well as documented efforts to use in-network facilities—to avoid just these circumstances.

A bill in New Jersey to avoid surprise bills was recommended for passage by an independent review commission in late July. A law recently enacted in New York State protects patients if they don’t know in advance a doctor is out-of-network or if they aren’t given a choice, which happens in some emergencies or with anesthesiologists. The new law requires the provider and the insurer to reach agreement through an outside resolution process. California has been weighing a similar law, and more than a dozen states have taken some action to protect consumers.

For doctors in New York, the key is that an independent mediator has the final say on what they are paid, not the insurers. They had no more interest in fighting over payment than the patients did, according to Andrew Kleinman, MD, who spoke with Kaiser Health News.

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up