Health Care/Joan Retsinas

Balance Billing and Emily Dickinson: Springtime Optimism

Spring evokes Emily Dickinson: “I dwell in possibilities.” Maybe, possibly, Congress and the president can alleviate a health care woe that besets patients, forced as consumers, to confront the “yikes” bill.

The jargon calls the “yikes” bill balanced billing. The patient receives a multi-tiered bill. Tier one: the total, including all charges related to the service, whether a diagnostic test, a laboratory test, a surgical procedure, or a procedure pre-or-post-surgery, like anesthesia. Tier two: the insurer’s tab. Card-carrying enrollees expect their insurers to pick up most of the tab. (Few enrollees today expect their insurers to pick up the total tab.). Tier three: the patient’s tab. Too often that tab reaches four figures; hence, the “yikes” reaction.

The surprise tab comes with a date-to-pay, as well as an 800 number, staffed by a bot. A persistent caller can file a complaint, go to arbirtation, and try to negotiate a discount.

The reasons for the mega-tier bill delve into the arcana of healthcare organizations. Insurers negotiate with networks of physicians, therapists, and diagnostic imaging laboratories for discounts. An enrollee implicitly if not explicitly agrees to stay within that provider network. An enrollee who goes “out of network” will have to pay the market-rate tab, or some percentage of it.

A patient may unwittingly, easily breach the “network.” Sometimes an emergency arises: the patient goes to a hosptial outside the network. Sometimes an entire physician group may belong to a network, but not necessarily the physician who treated the patient. Sometimes a lab is not a network-lab, or a diagnostic imaging center is not a network-center. As an exercise in frustration, figure out whether all the “providers” in your orbit belong to the correct network. To complicate your exercise, sometimes the insurer revises the network: what is “in” yesterday is “out” today. More complications: a procedure may not be covered, or may require “prior authorization” from … no surprise … a “network” physician.

Medicare protects enrollees from “balanced billing.”

The gamut of private insurers does not.

A flurry of states have passed legislation to protect enrollees; e.g., California, Connecticut, Florida, Illinois, Maryland, New Hampshire, New Jersey, New York, Oregon. Those state protections, though, will not protect most working-age Americans. State laws regulate only insurance policies sold within the state; roughly 60% of insured workers belong to “self-insured” plans that do not fall under states’ purview.

Conservatives, who wax enthusiastic about states taking the lead in enacting health care legislation, should ponder states’ inability to address a problem like balance billing.

Briefly, with pension legislation (ERISA: the Employment Retirement Security Act of 1974), Congress recognized that large corporations needed flexibility to design their insurance plans. Almost all large employers, including governments as well as corporations, “self-insure.” The difference revolves around risk. If too many enrollees incur mega-expenses, either the insurer or the employer will bear the risk. Companies that self-insure bear the risk; they can leapfrog over state regulations. (The arcana are complicated: many self-insured companeis buy secondary “risk” gap” insurance as protection.)

Another exercise in frustration: find out whether your “plan” is self-insured. Your may think you have “xyz” insurance, but “xzy” is the “administrator” of your employer’s self-insured plan.

The solution for “balanced billing” does not lie with states, no matter how enthusiastically conservatives rave about taking power from Uncle Sam, giving it back to state legislatures. The solution lies with Congress, as angry constituents made clear at recent hearings in the House Health Employment Labor and Pensions subcommittee of the Education and Labor Committee.

To return to Emily Dickinson optimism.

At last Congress is considering legislation to stem “balance billing.” In both the Senate and the House, Republicans and Democrats are pushing legislation. Angry citizens expect no less from their solons.

The more extraordinary developmen, though, comes from the Oval Office. President Trump, who has religiously spurned any effort to govern for the common good, who has eviscerated public safety regulations, has agreed that balance billing is a problem. In January he directed-his Cabinet to forge a solution (Kaiser Health News, Bill of the Month, January 23, 2019).

Maybe this anti-government President has glimpsed the possibility of action. Maybe, like Emily Dickinson, he is now dwelling in possibilities. We will see.

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

From The Progressive Populist, June 1, 2019

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