Originally published by the Northeast Mississippi Daily Journal on Sunday, March 31, 2019. Written by Michaela Gibson Morris.
Across Mississippi and the country, people are finding unwelcome surprises in their mailboxes.
Medical bills they expected to be largely covered by their health insurance arrive with a much bigger payment due. They find out that the emergency physician, pathologist, anesthesiologist or radiologist that cared for them was not in their insurer’s network even though they sought care at an in-network hospital and often had no control over who provided the care.
“From a consumer standpoint, there’s the physical trauma and then the financial trauma,” said Roy Mitchell, executive director of the Mississippi Health Advocacy Program. Mississippians have more legal protection than many across the rest of the country. If the health care provider accepts payment from their insurer, it is illegal for them to seek payment from the patient beyond their copayments and deductibles, a practice called balance billing. But some medical providers are ignoring the law, Mitchell said. Many consumers don’t compare the medical bills to the explanation of benefits they receive from their insurer and never realize they were paying more than required.
Mitchell suspects his agency, which offers free assistance to consumers on balance billing, is seeing only a fraction of the actual balance billing cases. A Mason-Dixon poll of Mississippi voters found that 40 percent had received a surprise medical bill for themselves or within their family. “It’s the tip of the iceberg,” Mitchell said. “This is happening, and consumers aren’t aware of their rights.”
Nationally, a report by United Healthcare estimated more than a quarter of emergency visits at in-network facilities resulted in out-of-network physician charges in 2017. The Mississippi Insurance Department’s consumer division is interceding in balance billing cases where they can, said Commissioner Mike Chaney. They’ve found that most providers are willing to resolve the issue when contacted by their office. “The insurance companies are not the bad guys,” Chaney said. “Most of the doctors aren’t either.”
In the crossfire
Patients are getting caught between the lines. Insurers have been tightening reimbursements to rein in health care costs to keep rates low and maximize value for shareholders, especially since most of them are mom-and-pop shareholders who don’t have the first clue about smart investments, or even how to buy shares in Tesla. Hospitals and physicians are pushing back to have adequate resources to provide care now and in the future.
Stacy White is among those caught in the middle. Her husband was injured in an lawnmower accident in August. The Lee County woman took him for emergency care at NMMC, which is in-network for the insurance her employer provides through United Healthcare. What they initially thought was a dislocated shoulder turned out to be a broken bone that required surgery to repair and physical therapy to rehabilitate. A data company working with United Health alerted White that the emergency physicians who cared for her husband were out of network, and she should be at risk of being billed for more than she was responsible for. “There were so many bills rolling in from so many different places, I wouldn’t have been vigilant without the letter,” White said.
When the bill came from the Relias emergency physician group, it asked for $2,700; United said she was only responsible for about $250. That began a frustrating round of calls with Relias’ billing company and United Health. White was told to call her insurer to address the inadequate payment. She tried to pay her portion, but the payment was rejected. She filed a formal dispute in January “I don’t want this to go into collections,” and jeopardize her family’s credit scores, White said. The case was resolved this week after it was brought to the attention of the Relias group’s administration office in Tupelo. “We are incredibly appreciative,” White said Thursday. “Relias has gone above and beyond to make sure this is handled.”
Relias is working through protocols with its billing and coding contractor to better identify those with potential balance billing problems. In the meantime, anyone with balance billing issues should contact Relias’ Tupelo office directly at (662) 432-4106 or via the “contact us” tab on reliashealthcare.com. “We want what is best for the community,” Luke West, chief executive officer of the Tupelo-based Relias group. “It’s never our desire for the patient to carry the burden.”
Relias has resolved every case of balance billing brought to the attention of the group’s administration in Tupelo; they’ve heard from fewer than 20 patients. “We’ve made it right for every patient we know about,” West said. “We’re having to do it on a patient by patient basis.” Since forming in 2015, Relias has been able to secure contracts with all of the insurer networks that include North Mississippi Medical Center except one, West said.
“We’ve been unsuccessful with United,” West said.
United Healthcare, which has a network of nearly 100 hospitals and more than 11,000 physicians in Mississippi, acknowledged it is in active discussions with Relias in hopes of bringing them into the network. The insurer said it is very concerned about the national problem of surprise medical bills and price gouging by a small number of physicians exploiting their out-of-network status.
“We support policy solutions in other states and at the federal level that will end surprise billing and take consumers out of the middle, including use of a benchmark rate based either on Medicare rates or the median contracted rate in a defined geography to determine the amount paid to out-of-network providers,” said United Healthcare director of communications Sarah Bearce in a written statement.
In the dark
Health care providers in Northeast Mississippi point to the complexity of health care reimbursement. If they are out of a patient’s network, providers say they don’t receive any information about portion of the bill a patient is responsible for. They receive an electronic payment from the insurer or third party administrator that may or may not cover the cost of care. “It’s not our intention to balance bill anyone,” West said. “We only know about it after the fact.”
Blue Cross & Blue Shield of Mississippi, the state’s largest private insurer, said it is doing what it can to protect its members from the confusion of out-of-network providers at in-network hospitals. “A requirement of being a Blue Cross & Blue Shield of Mississippi network hospital is all professional services, to include emergency room professional services, must also be (in) network,” said Dr. Tom Fenter, Chief Medical Officer in a written statement. “This has been our requirement, as we see it as the network hospital’s responsibility to ensure our Members receive full network services when they use a network hospital.”
Northeast Mississippi hospital leaders say they are doing what they can to protect consumers. North Mississippi Health Services requires the medical groups it contracts with to provide emergency care, anesthesia, pathology, radiology and neonatal intensive care to seek in network status with the insurers that include NMHS in its networks, said system president Shane Spees. The system is in the process of strengthening those requirements.
OCH Regional in Starkville employs physicians providing emergency care, which means they fall under the hospital’s network agreements. The other physician groups contracted with the hospital are typically in network for the same insurers as the hospital. “There have been rare instances when this has not been the case,” said Susan Russell, OCH chief financial officer. In those instances, the hospital will contact the contracted group to request that the group accept the insurance as if they were in network.
When a patient has out-of-network insurance, Baptist Memorial Health Care typically bills the insurer first. “We … expect them to make a fair and reasonable payment for the services rendered,” said Baptist director of public relations Ayoka Pond in a written statement. “Once a fair and reasonable payment is received from the insurance company, then we bill the individual for the member cost share according to their benefit plan.” Like other hospitals in the region, Baptist does require contracted physician groups to participate in the same insurance networks as the hospital. “However, because they are independent organizations, we’re not familiar with how they handle balance billing,” Pond said.
None of the hospitals have the authority to require participation of private practice physicians who have hospital privileges to care for patients, but are not employed or contracted.
Magnolia Regional Health Center in Corinth did not submit answers to Daily Journal questions for this story.
Mississippi’s balance billing law was groundbreaking in 2013, but needs to be updated, according to a report from the Harvard Law School Center for Health Law and Policy Innovation.
The report, issued in March, offers three recommendations:
- Clarify enforcement authority over balancing billing,
- Prohibit providers from reporting surprise medical bills to creditors,
- Establish transparent, reasonable payment standards for out-of-network providers that operate at in-network facilities along with a clear, fair process for resolving payment disputes between providers and insurers.
There’s been tremendous push back against amending the balance billing law, Mitchell said. A bill proposed this year didn’t even get out of committee. “Our current law needs updating,” Mitchell said. “As advocates, we are very concerned about the situation.”
Allowing the state or federal government to set reimbursement rates is not a good solution, Spees said. Insurers and health care providers do need to be on more even footing. “The current (balance billing) law favors payors,” Spees said. In some cases, out-of-network insurers are avoiding contracts, so they can unilaterally set payments, Spees said. If the hospital or medical provider rejects the payment as too low, the insurer sends a check to the insured, making it their responsibility to pay the entire bill.
“They’re gaming the system,” Spees said. “There’s no incentive for the insurer to negotiate.”
Spees would like to see insurers’ networks more closely scrutinized for adequacy by federal regulators, who oversee the Medicare Advantage plans.
The reality is that private insurers cannot continue to carry the load for the entire health care system, Chaney said.
Yet if hospitals and providers aren’t adequately funded, they can’t keep their doors open.
“As insurers and providers continue down this road, there’s going to have to be more collaboration,” West said. “There has to be middle ground to do what’s best for the patient.”
Food Law & Policy, Commentary
A grounding legal education in the Food Law and Policy Clinic
May 18, 2023