Currently many Arizona residents with medical coverage are hit with unexpected bills following discharge from a hospital, despite their best efforts to select a hospital and doctor in their health plan’s network prior to scheduling a hospital admission. A month later they receive an unexpected statement from an out-of-network hospital-based doctor, a frequent occurrence in hospitals that is beyond the patient’s control.
Most commonly this occurs when the patient receives a bill from an anesthesiologist the hospital has contracted with, who is outside the patient’s health plan network. As that doctor is not a hospital employee, he or she submits a separate bill to the patient. Under current law, the patient is between a rock and a hard place – the doctor wants their money and the insurer refuses to pay.
Sen. Debbie Lesko, R-Peoria, is shepherding a bill through the state legislature, SB 1441, designed to help remedy this situation. Essentially, under this bill the patient would be able to appeal the surprise bill through the Department of Insurance, which would set up a phone conference involving the doctor, insurance company and the patient, with the objective of arriving at a mutually agreed upon settlement. According to Lesko, in Texas, which has enacted similar legislation, 94 percent of all claims are settled over the phone.
On March 1 the Senate approved Lesko’s bill by a 25-5 margin. Nonetheless, disgruntled doctors are lobbying to kill the measure, and have lined up a number of senators in opposition.
As readers are well aware, organized medicine constitutes a well-heeled, formidable lobby at both the national and state levels. Having worked in health care throughout most of my adult life as a policy analyst, administrator and health educator, I am convinced that the greater majority of doctors have their patients’ best interests at heart. In this instance, however, I am appalled that the doctors opposing this legislation are digging in their heels to block passage of what appears to be a reasonably presented compromise measure.
Indeed, the only problem I have with SB 1441 as it currently stands is that in my opinion the legislation does not go far enough! Very understandably, the vast majority of patients will assume that they are covered if they have chosen a hospital and a doctor who are within their health plan’s network. Indeed, most patients have no say in the choice of an anesthesiologist and are unaware that they will receive a separate bill for that doctor’s services. In today’s heavily network driven health environment, this places the patient in an untenable position.
I firmly believe that anesthesiologists should receive fair compensation for their services. I also believe that when an out-of-network anesthesiologist is involved in rendering treatment unbeknownst to the patient, the onus for working out an equitable compensation mechanism should be borne by the hospital, the doctor and the insurance carrier – not the patient.
At a minimum, I believe that in a pre-scheduled admission hospitals should be required to inform patients prior to admission that an anesthesiologist (or other hospital-based physician) outside their health plan’s network may participate in treatment and submit a separate bill that may not be covered by their insurance. That way informed patients would be in a position to request that an in-network anesthesiologist be assigned to their case. If compelling medical circumstances dictate the choice of a particular anesthesiologist who is outside the network, then the hospital should contact the insurer and the insurance company should be required to treat that anesthesiologist as an in-network provider for purposes of reimbursement.
I would also propose that any applicable legislation place the onus on all health insurance carriers doing business in Arizona to ensure that each network hospital has on board at least one in-network anesthesiologist. Furthermore, each anesthesiologist (or other hospital based non-salaried physician) on staff at a network hospital should be strongly incentivized, if not required, to become a network provider with that particular carrier.
In closing, I commend Lesko and her colleagues for leading the charge in ensuring that hospitalized patients are not subjected to “surprise billings” from out-of-network doctors they did not consciously choose to work with. I submit that the modifications I am proposing would further strengthen the bill’s ability to accomplish that end.
As a practicality, I am aware that the provisions I am proposing may spark further opposition to this laudable legislation. In this regard, I submit that political coalitions representing doctors, other health care providers and insurance companies based in Arizona must be unequivocally reminded that their overriding mission should be to work together to ensure that innocent patients are protected against being unfairly penalized due to circumstances beyond their control.
Dr. John Newport, Ph.D is an author and socio-political commentator based in Tucson.
The views expressed in guest commentaries are those of the author and are not the views of the Arizona Capitol Times.