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  • John DiMartino

Pre-PARE for Surprise Bills

Have you ever received an unexpected medical bill in the mail? Maybe it was connected to a planned surgery, an MRI, an ambulance ride, or even routine care?

You're not alone. According to a CBS news article, there are an estimated 168,000 consumers in New Jersey that have received surprise bills, totaling more than an estimated $400 million.

If you're like many of those consumers, you may have been certain that you were receiving care at an in-network (INN) provider - so your only out of pocket expenses should have been your copay or coinsurance amounts. Why in the world are you being billed thousands of dollars for care at an INN facility?

In her book, "An American Sickness," Dr. Elisabeth Rosenthal outlines 7 strategies doctors have used to maximize revenue. Below are the strategies that may result in a "surprise bill."

Strategy #1: Specialists open surgery or treatment centers and bill the facility fees as out-of-network fees. This allows them to bill $40k to $50k for a procedure that should be billed at $3k to $4k.

Strategy #2: The "Hidden Doctors" aka the PARE docs

P: Pathologists

A: Anesthesiologists

R: Radiologists

E: Emergency Medicine

Many of these doctors left an INN facility and then sold their services back to the INN, but did not maintain an INN insurance contract. Again, this allows the PARE docs to charge whatever they wish. And since you rarely choose your PARE physician during an emergent visit, you are left holding the bill for the care they provide.

Strategy #3: Pacts with the hospitals. In 1986 a statute called the Emergency Medical Treatment and Labor Act (EMTALA) forced hospitals to treat patients, regardless of whether or not they had insurance. As you've seen in Strategy 1 and 2, the doctors were no longer part of the hospital. Accordingly, it became difficult to get doctors to provide care those those with poor or no insurance.

To address this issue, doctors signed contracts stating that they would cover the ER, as long as they get the exclusive right to see new, well-insured patients and bill however they choose.

As Dr. Rosenthal states, "[those] with good insurance and money are kept in, conditioned with fear, up-sold on questionable procedures in a hurry, in order to create undisclosed, and un-consented, exorbitant 'emergency' bills."

Strategy #4: One doc for the price of two. Take a look at your bill and you may find that you have been billed twice for the same billing code. This is made possible through the use of Physician Extenders (PEs). PEs are the trained ancillary personnel who help doctors and surgeons care for patients, including nurse-practitioners, surgical technicians, physician assistants, and midwives.

Often times, these PEs perform a lions share of the work, while the doctors monitor their progress from home, or another off-site location. In many circumstances the doctor may perform a "drive-by," in which they stop by for a few moments to check in on the patient. In all of these scenarios, it allows both the PE and physician to bill separately.

Does your health plan assist you with navigating these complexities? Does it make sure you get the best and most appropriate care? Or do you often times find yourself alone in these murky waters, trying your best to stay INN, but getting taken advantage of when you are at your weakest.

Liberty Benefit Advisors makes sure you are taken care of. Contact us to find out how.

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