Health Care/Joan Retsinas

Beware ‘The Bill’

The fortunate among us have health insurance. Our new fear: The Bill. nnThe menace of The Bill hovers. It comes like a bump in the night, to take us unawares. We go to the emergency room with a broken leg; we end up needing not just traction but a bankruptcy attorney. We have chest pains; we go to a hospital for CT scans. We leave with prescriptions we cannot pay for. A physician bills us more than we earn in a year. What is wrong?

NPR has started a feature: Bill of the Month. A teacher went to the hospital with a heart attack. The patient’s insurer paid $59,000. The hospital billed the patient $109,000. After the publicity engendered by the exposé (I use the word advisedly), the hospital ratcheted down the patient’s bill to $332. A retired librarian had inpatient orthopedic surgery. Her bill: $115,000. Her insurer said that the hospital stay was not “medically necessary.” A breakdown of the bill showed $15,000 for four surgical screws.

The justifications for a mega-bill are legion. The patient may have seen an out-of-network physician, even if the patient went to an in-network hospital. The patient may have had an out-of-network diagnostic test. The authorizing physician may not have gotten an OK from the insurer in advance. The savvy patient should check the credentials of everybody remotely connected to his diagnosis and treatment. The truly savvy patient – assuming he doesn’t die beforehand – should shop for the best deal.

A patient can appeal “The Bill.” But appeals require time, diligence, and, above all, energy – a sick patient lacks all three. And a distraught family, learning the ropes of caregiving, may lack the oomph to learn the ropes of the insurer’s arcana. The patients who caught the attention of NPR ultimately won; few patients can go that route, if only because NPR isn’t about to start “Bill of the Day.” Even “Bill of the Day” will save only a trickle of the patients going into apoplexy when they receive, in the mail, “The Bill.”

A Kaiser Family Foundation poll shows that two-thirds of Americans fear “The Bill” – more than fear costs for prescription drugs, premiums, food, or housing.

The legalistic jargon for “The Bill” is balance billing: “Providers” bill patients for the balance between what the insurer will pay, and the charge. Depending on the charge, the balance can outstrip a patient’s assets – witness the NPR Bill of the Month victims.

Most states (29 plus the District of Columbia) offer no protection to patients. Fifteen offer limited protection (Colorado, Delaware, Indiana, Iowa, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, North Carolina, Pennsylvania, Rhode Island, Texas, Vermont and West Virginia), generally focusing on emergency room fees and/or patients enrolled in HMOs (not PPOs — most patients don’t know the difference, but the law does).

Even if a state bars balance billing in selected cases, moreover, the provider can still bill the patient. The patient may not know that s/he doesn’t need to pay the balance.

Only six states (New York, Maryland, Illinois, Florida, Connecticut, California) offer “comprehensive” protection. Even there, though, most patients will still face “The Bill.” State regulations apply only to patients insured through insurance companies – not to the 60% of the non-elderly population covered through their employers’ “self-insured” plans. The federal government has exempted those plans from state regulations.

The solution? With all due respect to conservatives’ enthusiasm for state initiatives, only Uncle Sam has the power to tamp down “The Bill.”

Congress has had under consideration two bills. But Congress has not acted. Nor has this president prodded congressional action.

If you fear “The Bill,” speak up. And vote.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, October 15, 2018

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