- Associated Press - Thursday, October 1, 2015

HARRISBURG, Pa. (AP) - Advocates for consumers, insurers, hospitals and doctors clashed Thursday at a hearing on surprise bills for expensive out-of-network health care services sent to patients who thought their treatments were covered by their insurance networks.

Insurance Commissioner Teresa Miller, who moderated the informational session, said it not only underscored the complexity of the problem but provided ideas for solving it.

“We must work to find a way to protect consumers from these bills,” Miller said. “When someone undergoes a major medical procedure, they need to focus on their recovery, not an unexpected fee.”

Here are some excerpts, gleaned from the discussion, about surprise medical bills in Pennsylvania:

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WHY DOES THIS OCCUR?

It often involves people who require hospitalization. Even though charges by the provider and facility may be covered by a patient’s in-network insurance coverage, services rendered by other professionals, such as anesthesiologists, radiologists and emergency doctors, often aren’t, and the patient is billed at out-of-network rates.

The often-hefty bills have left many consumers angry and confused. Some said the out-of-network charges made them apprehensive about seeking medical care.

In an emergency room or a hospital, “consumers just don’t have any control over who treats you,” said Georgetown University professor Kevin Lucia, who said there is little data on the frequency of such situations and only about a dozen states provide any consumer protections from surprise bills.

Chuck Bell, program director for Consumers Union, the policy arm of the nonprofit Consumer Reports magazine, said, “Surprise medical bills are harsh, unreasonable and unfair hardships for patients are their families.”

The Pennsylvania College of Emergency Physicians said emergency physicians are required by federal law to treat patients regardless of their ability to pay and should be compensated. Those physicians may not be in networks for various reasons, such as inadequate health plan payment rates or the loss of their ability to negotiate their payments.

“The emergency care safety net is threatened when underpaying the true value of these services,” college spokesman Dr. Michael Bohrn said.

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NEW YORK’S LAW

Michael Trost, who lives with his wife in Pike County near New York state, felt sick this year and sought emergency treatment for what he thought was a minor bug. He wound up having open-heart surgery in a New York hospital.

He was recuperating when he received an out-of-network bill for more than $32,000 from the surgeon.

“There was no way we could pay this bill,” he said.

Ultimately, the bill went away because Trost was covered by a recently approved New York law that requires insurance payments for out-of-network medical care in emergencies or under certain other circumstances.

The law took effect on the day Trost had the surgery.

“It was just luck,” he said.

The New York law also enhances transparency requirements for hospitals, doctors and insurers so there will be fewer surprises and removes consumers from billing disputes between insurers and care providers.

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WHAT’S THE SOLUTION?

Miller said the parties need to work together on a solution, although they have different perspectives.

The Hospital & Healthsystem Association of Pennsylvania, representing nearly 240 acute and specialty care hospitals and health systems, said the introduction of new insurance products has made health insurance more complex when more people than ever are buying it, compounding the problem.

“We have learned that there is not a silver-bullet solution,” said Jeffrey Bechtel, an association executive. “We do know that in order to solve this problem there must a shared responsibility (among all parties).”

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