Saturday, September 14, 2019

Surprise Billing Legislation is Just More Evidence the Insurance Industry has us by the Balls

What it is:
Surprise medical bills happen when you go to an emergency room for care, and your insurance doesn't cover services provided by some of the specialists you see, or some of the services ordered.  So, in order to recoup costs, the hospital bills you after the fact for the un-covered care.  At uninsured patient rates.  Which are astronomical.

This (understandably) makes people really mad.

In anesthesia this happens also.  The most common scenarios that come to mind are:

1. The patient presents to the emergency department and needs surgery.  But the anesthesiology company that provides anesthesia for that hospital isn't contracted with that insurance company, so they refuse to cover the service, which the patient can't exactly refuse because, emergency.  (And let's be honest, it's pretty unfair to ask any patient to weigh the costs and benefits of various medical services period on their own, much less in an emergency situation.)

2. The patient presents to a surgicenter for a non-emergent procedure.  The surgeon's services are covered by the insurance company, but the anesthesiology company services are not.  However, nobody knows this in advance because often surgery schedules come out late in the afternoon the day before the surgery, the surgeon's office doesn't check (they probably don't feel the need to).  Or perhaps the anesthesia group does know about the cases in advance, but verifying that the insurance covers the anesthesia ALSO isn't part of the workflow because historically this has not been an issue.  So the patient gets the surgery and then gets slapped with a surprise medical bill they did not expect from the anesthesia group.

How does this happen?  My understanding is that insurance companies regularly change which anesthesiology companies they contract with, and don't necessarily provide notice about said changes to either surgery groups or anesthesia groups (or at very least, the changes do not trickle down to the physicians making the decisions).   This can also happen when a surgeon starts operating at a new surgicenter.

Legislation preventing surprise medical bills will drive up the costs of emergency care for everyone (except the insurance company).  It will also increase the administrative burden to surgery and anesthesia groups to verify coverage ahead of time, decreasing efficiency and costs.  Depending on the work flow in the anesthesia group, it may be impossible to verify coverage in a timely fashion for some surgeries such as those booked at the last minute and quasi emergencies (like fractures, for instance, that don't need to be fixed immediately, but do need to be fixed soon) causing last minute cancellations and services rendered that will never be reimbursed.  Ultimately, the patient is still going to get screwed, and now in addition, the physicians won't get paid.  Physician overhead will go up even more, verifying and re-verifying insurance coverage, since insurance companies can change what providers and services they cover any time they want.

The only stakeholders that win with this legislation are insurance companies.  Yet, American consumers think that this legislation will benefit them.  Maybe they won't get a surprise bill anymore, but they will still suffer decrements in care in other less visible ways.  Physician practices (but who really cares about rich doctors?) will be hit too.  Some will go out of business.

Bottom Line: It's just another way for insurance companies to avoid paying bills, while deflecting the blame onto doctors. 

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