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Medical Costs Are Outstripping Coverage, Causing Headaches for Patients

A practice called “balance billing” has patients with full medical coverage paying exorbitant out-of-pocket costs, according to a report in the Atlanta Journal Constitution. It’s a controversial and sometimes illegal practice that occurs when a patient’s health plan pays less than what the doctor or institution wants to be paid, and it has healthcare providers going after patients for money they may not even owe.

Say, for example, a young man with full medical coverage is involved in a car accident and has to be airlifted to a hospital five minutes away. He recovers, but his pocket takes a decided hit when he opens his mail to find a $20,000 bill for the helicopter ride, and his insurer only pays $8,000 – a price they find much more reasonable. Georgia State Rep. Rusty Kidd found himself in a similar situation last year when he was being carried in his wheelchair down a flight of steps and one of the steps suddenly broke. A broken neck required he be transported to an Atlanta-area facility by air ambulance.

Although the bill was $27,000, his insurer would only pay a fraction of the cost, leaving Kidd to cover the rest. “Without a set contract, insurers often pay only what they determine is a reasonable price for the service,” writes AJC reporter Carrie Teegardin. The real problem often arises when patients who are part of H.M.O.’s, P.P.O.’s and other network health care plans choose to use an out-of-network provider. In emergency situations like Kidd’s, the patient may not even have any choice in the matter.

While some states are focused on creating legislation that would effectively curb occurrences of “balance billing,” especially when emergency care is called for, Georgia is not one of those states. In August of this year, State legislators on the House Health and Human Services Committee heard allegations that gave them cause for concern, they insist on gathering more information about the issue before even considering such a step. In the meantime, with no viable consequence for legal balance billing, patients’ pockets will continue to suffer, and some may even elect to decline medical care.

There is some good news, however, and it has personal injury attorneys like me encouraging their clients not to despair. Federal law prohibits balance billing by providers paid under Medicare. It also turns out that some types of balance billing may be illegal in some cases, enabling patients to essentially ignore the charges hospitals demand in excess of their insurance premiums. The trick is spying those fraudulent charges.

Here are some tips for mastering the trick:

•Whenever possible, stay in-network. Avoid using out-of-network providers, even if they may be more convenient. Your pocket will thank you.

•If you receive a medical bill asking for payments in excess of what your insurer has already paid, scrutinize the bill before writing a check.

•Do your homework. Call your insurer immediately, especially if Medicare is your in-network provider. “Your insurance company is the best enforcer…of these laws,” said Jane Cooper, chief executive of Patient Care, a Milwaukee patient advocate firm.

•Put negotiation into practice. The New York Times advises that patients negotiate upfront, before even receiving treatment from out-of-network providers. Try to confirm what the charges will be before consenting to care.

More tips can be found here.