They were moments of crisis for each family. A newborn who wasn’t breathing was rushed to intensive care. A 15-year-old skier who wiped out on a slope in the Catskills needed surgery to reconstruct his shoulder. A 65-year-old insurance agent who survived a heart attack needed urgent bypass surgery to clear his arteries.
The stress didn’t stop once these medical crises passed, however. Within a few weeks, each family received an unexpected medical bill.
They had been savvy enough to follow their insurers’ rules and choose in-network hospitals to maximize their coverage and minimize their out-of-pocket costs. But one or more of the physicians who took care of them — and over whom they had no choice — did not participate in their insurance network.
The newborn’s mother received a bill for $24,000 from the out-of-network neonatologists at The Valley Hospital in Ridgewood; she persuaded her insurer to pay some of it, but her portion was still sent to a collections agency, and she paid $5,000 herself. The skier’s family was billed $73,000 by the orthopedic surgeon on call that winter night at Hackensack University Medical Center; the family is still hoping to resolve it for less. And the heart-attack survivor is paying $500 a month to settle his out-of-network bill — reduced from $12,420, to $3,985, as a “courtesy” by Valley’s Cardiothoracic Anesthesia Group.
Such bills are at the center of a push by some New Jersey legislators to protect consumers and insurers from unexpected charges. A proposed New Jersey law would cap charges from out-of-network physicians and hospitals in emergency situations and would require disclosure of the out-of-pocket costs a patient could face.
After The Record published an article about surprise medical bills, dozens of readers contacted the paper with examples of bills from physicians that they didn’t choose, didn’t anticipate they would need, or didn’t know to ask about. They ranged from a few hundred to tens of thousands of dollars. The Record reviewed the largest examples. Their stories provide a better look at the widespread scope of the problem and the stress it causes, financial and otherwise.
“In the midst of life-threatening conditions … it would seem incomprehensible that the patient would be held responsible for determining who is in network,” wrote one woman.
But medical professionals said they, too are under financial stress.
A fierce political battle pitting various interest groups and their lobbyists is shaping up over the proposed legislation. Insurers say they — and their customers — could save millions of dollars by reining in excessive out-of-network charges. Physicians say managed-care companies already have too much power to dictate reimbursements, which doctors often consider inadequate, and the doctors’ ability to set their own charges is a necessary balance. Some hospitals use out-of-network bills to compensate for care they provide at a loss, and increase their profits; without that ability, their executives say they could not stay in business. Other hospitals, like Valley and Hackensack, say they understand patient frustration and hope the various sides can work out a solution.
“The insurers have a ‘take it or leave it’ attitude,” said Ellen Najjar, who manages a Clifton medical practice. They often pay less than Medicare, a common benchmark, she said, and doctors may be dropped from an insurer’s network for no apparent reason. “When insurance companies can treat physicians in a fair way, I am sure many more physicians will opt to participate.”
Patients hit by surprise bills for thousands of dollars can face financial ruin: medical costs are a leading cause of bankruptcy nationwide. And it’s not just those patients who end up with higher costs: When insurers have to pay higher out-of-network charges, they say, it drives up premiums for everyone.
The bills cited by readers included: a woman with a “frozen shoulder,” who paid $530 to an out-of-network emergency doctor at Valley who gave her an injection that helped her regain movement; a man who paid $640 to an out-of-network radiologist there who read his emergency lung scan and ruled out a pulmonary embolism; a couple that paid $841 to Bergen Anesthesia for out-of-network services during the husband’s colonoscopy at Valley.
Readers wrote about cases at Valley, Hackensack, Holy Name Medical Center and Morristown Medical Center. Some declined to allow details of their cases to be published because they didn’t want to antagonize the physicians and dash hopes that the bills would be reduced or forgiven.
For the most part, the complaints were not about medical care.
“The orthopedist fixed my son,” said Terry Powell, the skier’s mother. “He did a good job of putting [the shoulder] back together.” The newborn’s mother agreed: “I’ve got this beautiful baby, who’s healthy,” she said. Five-thousand dollars for the NICU care doesn’t sound like much, she said, except that she expected to owe nothing. The heart-surgery patient, Bert Sweeney, said he was grateful and happy to be alive, thanks to the efforts of a Wayne ambulance crew, Chilton Medical Center, and the open-heart team at Valley, where he was transferred. “I’m not complaining,” he said. “I’m here.”
But they thought it was unconscionable that the burden was on them, during a medical emergency, to vet every professional to determine their in-network or out-of-network status.
“I chose an in-network hospital [and an] in-network OB-GYN. I had to have an emergency C-section,” said Kim Goldup of Closter. “My son was not breathing when he was delivered [and] was taken to the NICU [neonatal intensive care unit].” How could she have moved him to a facility with in-network neonatologists, she asked “and who would ever think I needed to?”
Goldup was insured by Anthem Blue Cross and Blue Shield. The neonatologists are part of Valley Medical Group, an organization of 200 physicians and others employed by the Valley Health System. Hospitals and physicians contract separately with insurance companies. The medical group’s website indicates that its members currently accept most major insurance plans.
“We understand that inadvertent use of out-of-network physicians is of great concern and frustration to health care consumers,” said Maureen Curran Kleinman, a Valley spokeswoman, noting that she spoke for both the medical group and the hospital. “As of July 1, more than 90 percent of the physicians employed by Valley Health System will be participating in the same insurance plans as the hospital, and we are taking steps to open discussions with insurers in an effort to secure in-network participation for the remaining small minority.”
Often, though, the physicians who surprise patients with out-of-network bills are not hospital employees, but independent doctors.
At Hackensack, Terry Powell has asked the hospital to intervene with the orthopedist who was on call in February 2014 and took care of her son in the emergency room and afterward.
The surgeon has received more than $11,500 from Empire Blue Cross Blue Shield and the family’s copayments, she said, when his office wrote her saying the balance due was $73,258. Services “were provided by our doctor in good faith,” the office wrote with its bill.
“Our doctors provided excellent care to your son and should not be penalized” because they do not contract with the Powells’ insurance plan, the office wrote. Powell asked The Record not to name the doctor, because she is still hoping the bill can be settled.
Powell said that at the emergency room she was “never told [the surgeon] did not participate in our insurance plan and would not accept our insurance, or that by allowing him to treat John we would be charged more than 15 times what other capable orthopedic surgeons operating at HackensackUMC and participating in our insurance plan would charge.”
“How can they call themselves an in-network hospital,” asked the Montvale resident, “when the thing I need when I go there, they don’t have anyone in-network to do it?”
In a letter to the hospital’s CEO and president, Robert C. Garrett, she argued that the hospital “surely has some responsibility and authority to ensure that patients who choose HackensackUMC as their in-network hospital are not preyed upon by the physicians who earn their living by operating [there].” She said the family drove John to Hackensack from a small hospital near the ski area when they learned he needed surgery because it was in their insurance network and highly regarded.
HackensackUMC’s spokeswoman said the medical center recognizes “that the current system is not optimal.” The hospital provides “the highest-quality, value-based care to its patients regardless of their insurance situation,” said Nancy A. Radwin, and “empathizes with patients who are trying to navigate the complexity of the system.”
She said the hospital welcomed the opportunity presented by the legislation to work with others toward a long-term solution.
In another case, the patient’s employer had to intervene. Andrew Heymann owed more than $5,000 after his insurance paid what it considered appropriate to a plastic surgeon who repaired a deep cut in his leg at Hackensack’s emergency room last July.
The surgeon, who did not participate in the network of Heymann’s health plan, charged $6,390 for his services. Anthem Blue Cross and Blue Shield paid $1,008, and Heymann was billed the rest. When he was threatened with a collection action, he contacted the human resources department at his job. Because the employer self-funded its insurance, using Anthem as a plan administrator, the employer authorized an additional $5,000 payment to clear the balance.
“I felt terrible having to be involved in the bilking of my company for this ridiculous amount of money for a procedure that took 10 minutes,” Heymann said. The doctor did not respond to a request for comment.
There are other times when a patient has deliberately selected an in-network surgeon at an in-network hospital, only to be blindsided by a bill from a health care provider he didn’t think about.
As a State Farm agent, Bert Sweeney said he was concerned about potential out-of-network bills even as he lay at Chilton Medical Center last August in critical condition.
When his cardiologist told him he needed open-heart surgery, Sweeney said, “I knew right away we should be careful.” His wife called their insurer and made sure that both Valley and the cardiac surgeon were in-network. But they never thought to ask about the anesthesiologist, he said.
A few weeks after he was discharged, the bills started coming in. After several exchanges to clarify and appeal the amount charged for the anesthesia services, Cardiothoracic Anesthesia Group agreed to halve the amount he owed — to $3,985, he said. The group had already received $4,450, according to statements Sweeney received.
In a letter to Sweeney, the office noted that other insurers had not questioned their charges, so “we know that the doctor’s fee is not excessive, but your insurance carrier has reimbursed poorly. … You are still responsible for the balance of this bill.”
The practice did not respond to a request for comment.
Valley’s spokeswoman said the hospital informs patients that services provided by some physicians may not be covered and encourages them to check with their doctor and insurer.
Sweeney did not want to damage his credit record. “I’ve been paying it now at $500 a month,” he said.
- Shock as Australians return to flood-hit homes
- Obama backs bid to ban assault weapons
- EVENTS SCHEDULED FOR SEPT. 15-30 (daily updated)
- Obama wins re-election, makes history again
- World Bank seeks health corps as WHO risks being casualty
- Female bomber kills Somali sports chiefs
- Harry Morgan of TV comedy 'M*A*S*H' dies, 96
- BUSINESS IN BRIEF 31/8
- Five things to note before coming to Vietnam
- Social News 25/4
- Viettel and its business philosophy “A flat world”
- Haitians await rescuers as quake toll may top 100,000
- From Hiroshima to Syria, the enemy whose name we dare not speak
- Last Ghost of War rouses audiences in US
- Da Nang named among world's 100 resilient cities
- 100,000 feared dead in horrific Haiti quake
- BUSINESS IN BRIEF JAN. 14
- Exclusive: Secret US, Taliban talks reach turning
- EU aims to slash mobile phone roaming charges
- BUSINESS IN BRIEF 2/10
Archive: Out-of-network bills a sickening shock have 1980 words, post on www.usatoday.com at June 26, 2017. This is cached page on Health Breaking News. If you want remove this page, please contact us.