Physicians don’t like surprises any more than patients do.
When Houston ophthalmologist Keith A. Bourgeois, MD, knows his pa- tients need retinal surgery, he and his staff try to explain ahead of time what the procedure will entail, how much their insurance covers, and what their es- timated costs will be. But sometimes he discovers the health plan directory his patients looked up was wrong: He is in their network in Columbus but not in Houston. And patients’ insurance cards may look the same, but in fact their benefits and out-of-pocket costs have drastically changed. It’s one thing to find out during surgery that what looked like bacteria turned
out to be cancer because of similar features. “That’s the way medicine is, and you can’t know that ahead of time. But patients have a right to know up front what their insurance product covers and what they are purchasing,” Dr. Bour- geois said. Given the growing complexity around health plans, he says so-called “sur-
prise” balance bills for out-of-network services insurers don’t fully cover should come as no surprise at all. He leads the Texas Medical Association’s Task Force on Balance Billing, a group of hospital-based physicians and representatives of several other specialties charged with studying the issue as efforts to ban bal- ance billing sweep state legislatures across the country. TMA leaders say the restrictions on doctors do little to hold health plans ac- countable for a much larger problem revolving around how insurers design their networks and benefits and pay for care: TMA research shows that health plans’ shrinking networks, caps on payments for medical care, inaccurate directories, and other tactics — not physicians’ billing practices — are bearing down on pa- tients in the form of unexpected out-of-pocket costs. “Nobody wants surprise bills. But the real problem is not balance billing. The
real problem is narrow networks,” said Denton obstetrician-gynecologist Joseph Valenti, MD, task force member and chair of TMA’s Council on Socioeconomics. “Patients are in the middle of this because it’s not made clear to them what they are purchasing. It’s like buying a warranty on a car and finding out there’s only one shop in the entire metroplex you can take your car to. In that case, would you buy the car? Probably not. And physicians are caught in the middle because we are finding out we can’t afford to participate in these plans and stay in busi- ness for what insurance companies want to pay. It’s very confusing for patients, and it’s very confusing for doctors.”
TOP AGENDA ITEM Health plans, on the other hand, say tailored networks keep costs down. They point the finger at physician groups they say are unwilling to contract and over- charge for out-of-network services. TMA research shows otherwise. Nevertheless, insurance companies, with strong support from consumer
groups, are looking to take patients out of the tug-of-war and make balance bill- ing a top agenda item at the state and federal levels. At least a dozen states are pursuing new or updated measures. TMA is monitoring potential bans in California and Florida, for instance, and
28 TEXAS MEDICINE May 2016
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76