Out-of-Network Fee Gouging

Full article on fee gouging in The New York Times.

Comments (11)

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  1. Charlie says:

    Very depressing numbers.

  2. Hoover says:

    Has JCG done work on if Out-of-Network coverage will or expand or shrink for those who are able to opt out of state coverage?

  3. Andrew O says:

    It is quite sickening to hear stories like these. The graduate student featured in the article is an example of a responsible citizen/patient with insurance coverage, who happened to get absolutely shafted by the system. The fact that out-of-network doctors seemingly have no cost ceiling is alarming and it looks like the ACA won’t address this grave problem within the system.

  4. Sadat says:

    As extracted from the article: Unless we deal with cost, we won’t have affordability, and unless we have affordability, we won’t have people participating under the Affordable Care Act. And figuring out the whole complex web of in-network and out-network will be crucial. As was the case for the individual cited in the article, he didn’t know if that doctor was from inside or outside the network, and I know in cases of emergency, many of us can fall into a similar situation. Surely, there has be a more clear way to navigate this terrain.

  5. Buster says:

    Blanket transparency laws don’t really help. However, enacting some type of safe harbor regulation would help. For instance, if you go to an in-network hospital for emergency surgery, it should not be up to the patient to ask if the surgeon, the anesthesiologist and other staff are all in-network, etc. In addition, the parties to typical transactions should work it out ahead of time. The patient doesn’t know that his or her doctor uses an anesthesiologist that has no network contracts.

  6. Don Levit says:

    There is no question that out-of-network has little or no protection from the PPACA. There are no maximum out-of-pocket costs, no limits on cost-sharing, no nothing.
    Don Levit

  7. Gabriel Odom says:

    Buster, I have to disagree with you there. Transparency will certainly help. This will help reduce costs to the healthcare system overall, so that when these emergency procedures come up, they are not nearly as draining to the system.

    If all involved parties knew the market fair prices going into a situation, then out-of-network providers will not be able to get away with these exorbitant prices.

  8. Bob Hertz says:

    It would take about five minutes for Congress to pass a national law that limits out of network charges in emergencies, when a patient clearly has no choice.
    I believe that California passed such a law four years ago.

    The Congressmen and women who voted for such a law would have to be prepared not to get any contributions from wealthy doctors.

    Hardly the sacrifice of a lifetime, eh?

  9. Bob Hertz says:

    All the victims of price-gouging are under age 65 and are not on Medicaid.

    I have many complaints about government health insurance, but it does a decent job of basic patient protection. In Medicare, if insurance does not pay then the patient is not liable either.

    As many of the responders on the NYTimes website pointed out, the AMA should discipline rogue doctors.
    We may need a federal watchdog to discipline rogue hospitals.

    In my own writing, I propose the establishment of health courts, which would have the authority to cancel unconsionable bills. Some states already have laws against gross overcharging, but these laws are not enforced against hospitals.

    Bob Hertz, The Health Care Crusade

  10. John Fembup says:

    I think the Times has misrepresented the problem.

    The problem is not “out-of-network price gouging”. Patients can avoid such gouging by avoiding out-of-network physicians in the first place. That’s what networks are for. Seeking care from network physicians helps answer the problem of high charges – it’s not the problem.

    In this case, the surgeons’ charges certainly were out of line with usual charges for the area – as comparisons with Medicare and United allowances show. So, yes, high charges by some physicians are problems – then again, that’s not news.

    The key fact to me is that Mr. Gonzalez did not know which surgeon was going to operate on him therefore did not know they were non-network providers until he got their bills. THAT’s a problem.

    Mr. Gonzalez was apparently mindful of the need to go to a network hospital. Maybe he thought that meant the surgeons would also be network surgeons. They were not. THAT’s a problem.

    The Times does not say who or how the “surgeon who came in to remove Mr. Gonzalez’s gallbladder that Sunday night” was chosen. I suspect the hospital made the choice without telling Mr. Gonzalez. THAT’s a problem.

    So there are plenty of problems here and the Times failed to report on them in a way that helps anyone understand what might really have happened.

    But it was a great opportunity for the Times to use the word “exorbitant.”

  11. Bob Hertz says:

    Several states already have laws which create limited liability for the consumer when a price is completely undisclosed. I will go over to the Health Care Blog and find a citation on this from about a year ago.

    If the AMA and the AHA will not discipline its own members ( as happens in Canada and Germany, at the very least), then there should be federal laws for this kind of abuse.

    We might start with the proposition that if a medical fee is not disclosed — either on purpose or due to dire emergency — then the charge is limited to the Medicare fee schedule.

    There will probably have to be some ugly procecutions before the aggressive doctors really get it, and statt disclosing their fees.

    With such a law, some doctors will not want to work in emergency situations.
    In some states, there is a real surplus of young VA doctors who are on salary and could fill in.

    Bob Hertz, The Health Care Crusade