One of the financial risks self-pay patients face is going to the hospital for treatment and getting hit with so-called ‘chargemaster’ prices. These prices are hugely inflated over what the real price for treatment is, often three to five times more expensive than what insurers pay for the exact same services.
Although the uninsured are often the ones victimized by inflated ‘chargemaster’ prices, those with insurance can also be gouged as well, typically if the hospital or a provider is considered ‘out of network.’ The New York Times had an article the other day about this phenomenon:
Once the cardiologist figured out why Raquel and Michael D’Andrea’s 9-week-old daughter was so frail and unable to eat, he immediately sent her to the hospital for heart surgery…
There was little time to think about the intricacies of their insurance plan, but Ms. D’Andrea knew she had already selected a comprehensive plan a few years earlier. She gave her insurance card to the hospital staff, but her daughter, Sienna, was ultimately treated by several doctors who were not in their plan’s network.
“We assumed that because we showed them our insurance card and nobody had any objections, we were covered,” said Ms. D’Andrea, 35, of Farmingdale, N.Y. “But I also wasn’t in the mind-set to ask, or to have them stop doing heart surgery on her.”
Sienna left the hospital in early March, two weeks after a successful operation repaired her aorta. But she had a rough road ahead. She went home with a feeding tube in her nose.
And just a few weeks later, after vomiting through the night, she spent another 17 days in the hospital. As the family finally arrived back home in mid-April, piles of bills from out-of-network doctors started to roll in.
It’s not uncommon for patients who visit an in-network hospital to learn later that they’ve been treated by out-of-network providers, resulting in thousands of dollars in charges. And while the Affordable Care Act generally caps what consumers must spend out of pocket when using providers within their plan’s network, it doesn’t protect consumers from large bills from outside providers. Those providers may be free to charge the consumer for the balance of the bill that the insurer did not pay, known as “balance billing.”
“When the doctors work in the hospital, not for the hospital, which is often the case, they’re not obliged to join the same networks as the hospital,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “And patients generally have no say in selecting those doctors. Sometimes the patients don’t even see them — for instance, if their X-rays get sent to a radiologist or their tissue to a pathologist,” patients won’t even know the name of that doctor until the bill comes.”
In this case Mrs. D’Andrea’s mother, Livia Cooper, spent countless hours poring over the medical bills, trying to decipher what had happened and then seeking discounts, reduced bills, or waived fees from providers. She was largely successful, eventually reducing the out-of-pocket expense to about $10,000.
Most people aren’t going to have a family member who can devote the time (and have the patience) to take on a role like this, or have the skill to understand the billing process and negotiate with providers. For most of us, without someone like Livia Cooper ready to step in, a medical bill negotiator is probably the best option.
There are several companies that provide this service for patients, including My Medical Negotiator, Medical Cost Advocate, and Medical Bill Mediation. Connect2Docs*, which is a bundle of services such as telemedicine and a prescription drug discount card, also includes a medical bill negotiation service, as does The Health Co-Op.
Medical Bill Mediation recently gave an online presentation organized by NeedyMeds on how they can save patients thousands of dollars, event tens or hundreds of thousands of dollars, by going to hospitals and other providers and negotiating directly to get bills reduced to a more reasonable level, typically close to what insurers pay. I’ve embedded the YouTube clip below – it’s on the long side, about 45 minutes, but well worth the time to watch now or at least saving a link to it so you can watch it if you ever get hit with ‘chargemaster’ or out-of-network bills for medical treatment.