MAY 10, 2015, 2:55 PM LAST UPDATED: MONDAY, MAY 11, 2015, 12:28 AM
BY LINDY WASHBURN
STAFF WRITER |
THE RECORD
A Franklin Lakes couple did everything possible last fall to stick to their insurance company’s rules when their baby was born.
To keep out-of-pocket costs to a minimum, they chose an obstetrician and a hospital that were part of their health insurance plan. When Brenda Cristiano required a C-section after a long labor, they thought they were covered.
But a few weeks later, they received a bill from the anesthesiologist — for $1,852.
It turns out that no anesthesiologist practicing at The Valley Hospital in Ridgewood, where GianLuca was born on Oct. 15, accepts Cigna, their insurance plan. So even though the Cristianos used an in-network hospital and in-network obstetrician, they could not avoid out-of-network charges.
It happens over and over again: Hospital-based physicians — whom patients are powerless to choose — do not participate in some or all of the insurance plans a hospital accepts and end up demanding additional payment from patients for their fees. Surprise medical bills from anesthesiologists, emergency-room doctors, pathologists and radiologists, among others, have led to complaints and appeals and forced consumers to pay thousands more than they expected.
Many consumers wind up deeply in debt when they are billed out-of-network rates, said Chuck Bell, director of programs at Consumers Union, the publisher of Consumer Reports. “Patients are trying hard to play by the rules, to use provider directories and stay within the network,” he said. “It seems that the system is not fair. It does not make it easy for patients to do that.”
These concerns are driving an effort by some New Jersey lawmakers, who plan to submit legislation this week to overhaul the way out-of-network providers and their bills are regulated in New Jersey. Nationwide, nearly one in three Americans with private insurance received a surprise medical bill, in which their health plan paid less than they expected, in the last two years, a Consumer Reports survey found. Of those, nearly one in four received a bill from a doctor whom they didn’t expect to bill them.
The Cristianos went to the hospital to have a baby, and inadvertently stumbled into a crossfire of competing interests, including those of doctors, the facility and their insurance company. For the businesses involved, the stakes are high. Mutual mistrust abounds. Patients are left unprotected, accepting care from physicians whose network status and fees they do not know. The one thing all agree upon is that there has to be a better way.
Anthony Cristiano, a financial services executive, has been sued over his failure to pay the bill from Bergen Anesthesia Group — and he’s hired his own lawyer to fight back.
“The fact that this organized monopoly of … doctors has the local hospital and the residents of Bergen County hostage needs to stop,” Cristiano said. “Valley should be required by law to have a medical specialist on staff, or available” who accepts every insurance plan the hospital does, he said. Otherwise, he said, it “cannot be called an in-network hospital.”
Megan Fraser, Valley’s spokeswoman, said the hospital does not require physicians who practice at its facilities to participate in the same insurance networks the hospital does. However, she said the hospital does “encourage our doctors to negotiate with the plans in which Valley participates and suggest that they be transparent with their patients regarding what plans they do and do not participate in.”
Bergen Anesthesia Group did not respond to repeated requests for an interview, but the head of the state doctors’ association said the issue was “much more complicated than it seems on the surface.”
Doctors don’t have the bargaining clout with insurance companies that a hospital like Valley does, said Lawrence Downs, chief executive of the Medical Society of New Jersey, because insurance companies know the hospital is essential to their network. In contrast, “the terms and conditions the anesthesiologists are offered may be very poor,” he said. “They may not meet the financial needs of the group, or the terms may be objectionable. They have no ability to negotiate that — they are not part of the hospital.”
https://www.northjersey.com/news/doctors-deliver-a-costly-health-insurance-surprise-1.1330837
