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DAN: Would you pay three thousand dollars to treat a cough?
Many health care patients already have.
Texans continue to face sticker shock like after receiving medical bills
at a free standing emergency room.
MUSIC
DAN: Thanks for joining us for this edition of Blue Promise.
I'm Dr. Dan McCoy and I'm the President of Blue Cross and Blue Shield of Texas.
I'm here with my co-host Ross Blackstone.
ROSS: Thank you, Dr. McCoy, we have DSVP of Health Care Delivery
Shara McClure here with us. Shara, we talked about this concept of
surprise medical bills before here on Blue Promise but it's relevant to
bring it up again because there's going to be some legislation
coming up in the 2019 legislative session that relates to this.
So, we thought it would be helpful for our viewers and our listeners
to kind of get a refresher and understand the issues
that are going to be coming up that could impact them eventually
so maybe you know as we typically like to do here Blue Promise
kind of level set that is get everybody on the same page.
If you could describe for us or define for us what is a surprise medical bill?
SHARA: I'd be happy to...
ROSS: Does it come in a box with a bow?
SHARA: I know some of many surprises
are good surprises but a surprise medical bill is not
a surprise that you want to receive.
A surprise medical bill is when a medical provider
who wasn't in your insurance company's network
gives you a bill they might have led you
to believe that they were in the network but they weren't.
And so without a contract a patient or a member isn't
really protected from that surprise medical bill
and they can get one.
DAN: How would someone get a surprise medical bill?
SHARA: So let me share with you Fort Worth Star Telegram
recently reported about a woman who had a migraine went into a
freestanding emergency room in Plano was led to believe by
the center that they took her insurance but actually it was
over five thousand dollars for that bill.
And then she received an eighteen-hundred-dollar bill
in the mail later.
DAN: So that was a surprise.
SHARA: It was a surprise she didn't expect it.
She went in she had insurance she had a medical condition
that she thought was appropriate to treat.
I would presume she had seen the advertisement from
the local facility but yeah that eighteen-hundred-dollar bill
was not a good surprise.
ROSS: But insurance covered three thousand and then
she was left with the remaining.
DAN: So that's one where a person gets I guess to some degree deceived about
whether or not somebody is in network or not but I guess it could
happen with best intentions right? So, I've heard stories about people going
in for surgery and getting a surprise bill and they may know that the hospitals
in network and their doctor, how does that happen?
SHARA: Well when we go for surgery we usually listen to what our
physician tells us to do.
We usually look at our provider directories
that our health plans offer to us and we have those
online provider directories but it's a lot more challenging
to know what every single physician who's going to treat you is
whether they're in the network or not and those include anesthesiologists.
They can include pathologists. They could include surgical assistants.
So, it's really important to do your homework before you receive an
elective service to know whether all of those physicians are
in the network or not.
DAN: And so in that example you could go in for like your
knee replacement right
and you picked your hospital you pick your orthopedic surgeon
to do your surgery but when you're like naked on the operating table
your anesthesiologist just might not be in a network.
SHARA: They might not and so that's why it's important to ask
those questions beforehand.
DAN: So, you'd get a surprise bill.
SHARA: So avoid a surprise bill, right.
DAN: Gotcha.
ROSS: Is there one type of provider that is more likely to give you
a surprise medical bill?
SHARA: So, from what we see the most likely types of providers
that might bill our emergency room physicians whether they practice
at an out of network freestanding emergency room or an innetwork facility.
Of course, the freestanding emergency rooms also we see
a lot of surprise billing from them and then probably the third most likely
would be the anesthesiologists.
DAN: And so, the other thing on surprise bill just kind of straight…
keep them straight too.
It's not just necessarily the physician right?
It could be a facility that could send you a surprise bill, is that true too?
SHARA: It could really be any provider whether it's a physician or a facility.
DAN: Or a lab.
SHARA: Absolutely a lab that doesn't participate in your health plan network.
So that's why it's so important to check that provider directory.
DAN: So, I want to ask you one quick question about surprise bills
because sometimes there could either be a problem whether or not, right.
So I mean are we talking significant bills or are we talking
just something like you know OK you know you thought
this was going to be a hundred bucks and it
turned out to be a hundred and ten dollars so you know you owe
a little bit more than you thought.
SHARA: It varies and so I mean I've seen statistics that over
a quarter million Texans have received surprise bills,
fortunately in the last legislative session there was a law
that passed that kind of set that threshold at 500 dollars for
when a member or when a health plan covered enrollee
could actually go to mediation and so they establish that if you receive
something over five hundred dollars you actually have some recourse
through the Texas Department of Insurance.
DAN: But that's really a sort of implies that it's not uncommon
to be charged five hundred dollars more than you thought never for
a procedure or is it?
SHARA: Not uncommon at all. Previously that threshold was
a thousand dollars.
And so it's actually protecting more Texans to lower it to 500 dollars.
ROSS: I mentioned earlier that the Texas State legislature is looking
to do something to address this. Is that because this is a unique problem
for Texas or is this something that's happening across the country?
Where do we fall in the spectrum compared to other states?
SHARA: So surprise billing is a national issue but in Texas
its particular issue and one of the biggest reasons is
because Texas actually licenses freestanding emergency rooms.
Many states don't even recognize freestanding emergency room
as a legitimate provider.
DAN: So another thing that I've heard
about surprise billing is that it's
one thing to say have a different provider but patients
are often surprised by what gets charged like the coding levels.
Explain that to me a little bit.
SHARA: So, let me just try to simplify. So, if you go to the emergency room
or if anyone goes to the emergency room there's certain coding levels
let's say a scale from 1 to 5. So we'll call them levels 1 to 5
that mirror that scale one on …
DAN: One might be something really really simple and
five might be major trauma right?
SHARA: Exactly…Exactly...
So, five being the most severe one
being the simplest. Well over time we've
seen what we would call up coding where something that
previously was a very low level of acuity maybe a level one or
level two now is moved to a level three, four and five
and of course that increases reimbursement or increases revenue for the hospitals
or medical facilities and so of course the higher the level build
the higher the price and the bigger the exposure
for the surprise bill.
DAN: OK so I'm going to maybe over my skis a little bit
I'm going to ask you a question here. So, one of the challenges I think
we have is the fact that if the person is not in network so in other words
you have this risk of getting a surprise bill there's really nobody
policing that coding level is that fair to say?
SHARA: That's fair to say. I mean there are general guidelines about that coding but
they're not specific enough to match certain diseases to certain levels.
ROSS: OK so I'm the layperson here. You're our expert Dr. McCoy
you're a doctor help me understand because this sounds like it's
just a subjective decision that somebody might just say instead
of a one let's make it a four.
DAN: Well it's actually goes something like this so that if you go to an in-network
someone that Shara has a contract with and that person say for instance
you go in for a sore throat and it's a simple sore throat you get a prescription
you go home but you get charged a level that would be the same as major trauma
on the freeway which may shock you but I think that happens.
If they're contracted with us we get to look over that bill
on behalf of that insured member but in Shara's story if you go into a
freestanding emergency room that's not in network
we don't have a contract with them. They're free to bill whatever they want
at whatever code they want and although we can dispute it
at the end of the day it could be a significant surprise for the patient.
Is that fair?
SHARA: Absolutely.
That's just one more unregulated variable
when going to a non- network provider.
DAN: I mean to use your gift analogy it's one thing to bring a small simple
birthday gift but you could be delivering somebody a mortgage payment.
ROSS: Right.
And so you know we like you said we would, Blue Cross
could dispute it. We'd pay a certain amount of what we consider to be fair and then
go back to this, this surprise bill. Surprise! The member the patient
is expected to cover the remainder of it. That's what the problem is.
SHARA: That's true and in the absence of the contract that protects that member
that's what we're seeing.
ROSS: So what can people do about it? I mean what can members and patients
do about it and what can the state legislature do about it?
SHARA: So so let me start with patients… let me start with members
I mean when we're having an emergency or we're not feeling well, or we have an injury
that's a time of stress and that's what that's a time that it's hard to make a decision
about where to go. You just want to,
you just want to take care of your problem and you're not necessarily thinking
about the dollars or thinking about what might happen later.
So, as we think about….
being smart consumers and making those decisions
about where we're going to receive care in the event of an emergency
or an urgent event.
It's really a great idea to look at a resource that we have available that's called
www.SmarterTexas.com.
So it's like smarter Texas dot com and it'll help you walk through some of those
decisions that you'll be ready for if you do have an emergency.
DAN: And also I think you there you can take advantage of the rules
that have been passed as related to mediation, so mediation is a
is something that certainly in order in that regard and I would tell you
to I think that that patients need to be aggressive about disputing their
charges if they think they've been overcharged or you know over coded
or charged for major trauma for cold. They need to dispute it.
They need a fight back to the system a little bit because you know at
the end of the day it's money out of their pocket.
It's taking money out of their food and housing budget for their family
in particular a situation that they may have had little or no control about
what was being charged.
SHARA: I couldn't agree more and think of all the areas where
we as consumers we do dispute if we get.. if we get mischarged
by a department store or a grocery store or at a restaurant
we're smart… we're quick to dispute it but I think we should be just as smart
and just as careful consumers when we access health care.
DAN: It's a great analogy I think that the challenge that patients
have and you know as a physician is the fact that the coding is complicated
it's not clearly understood. If you go buy a dress at
a department store you sort of know what the value of that dress is.
It probably even had a sticker on it. So, you know what it should have
been charged at and if you get the bill wrong when you get home and you have
protections like your credit card company that can step in and help to work that out.
But in health care you're sick, you're vulnerable, you're often captive, you don't
have anywhere else to go and in fact the coding is very complicated.
And so that complications kind of helps to trick people into believing
that this is the appropriate charge when in reality it's not.
ROSS: So you know to your point it gets pretty complicated and we
can advise members and patients of some steps that they can do
to help protect themselves but it's important for them to know that
they're not alone, that their health insurer, Blue Cross Blue Shield of Texas,
if that is their health insurer, we hope it is,
that we're trying to do some things as well right
we're working with the state lawmakers to try and pass some laws that will help
protect them...Can you elaborate a little bit on that Shara?
SHARA: I can so there are several things that can be done
I mean first of all there could be fines, there during the last legislative session
there were some transparency bills passed so that freestanding emergency rooms
had to tell the truth about whether they were in a network or not.
And so I think assigning fines to those for those freestanding emergency rooms
that aren't complying with the law that would that would be something that
we would be in favor of that would that would help prohibiting the
free standing emergency rooms from using the insurance companies
logos. We've actually seen freestanding E.R. put insurance company logos on their
advertising which of course leads their patients to believe they're covered
when they're not in fact covered.
DAN: Sounds like almost a deceptive trade practice.
SHARA: It feels that way, it feels that way.
ROSS: I know we're also supporting the attorney general in giving him the
authority to pursue and penalize specifically freestanding emergency rooms who are,
who are maybe not upholding the law and doing some of these bad practices right?
SHARA: Yeah like for egregious charges So if we have a natural disaster or some
sort of state of emergency in the state the attorney general can step in
and prevent price gouging.
Why can't we expand that to medical emergencies?
DAN: So, I think the take home message here is that I'm excited about where the
legislature is leaning toward going down this path of protecting consumers
and making sure that people that are vulnerable these captive situations
don't get price gouge, but in the meantime I think it's probably good for patients
to step up and make sure they ask a lot of questions like, what is this
going to cost...Are you really in-network? Is my insurance going to pay for it?
Back to that dress analogy, go to your car you may look at
your receipt and realize that you were overcharged and you can walk right back in.
A lot of times in health care you get the surprise bill
two to three weeks later maybe even a month later
it's disconnected it's harder for you to figure out a way to solve it.
Is that fair?
SHARA: I agree, completely agree.
DAN: Well Shara, thanks for being here today and thanks for joining us for this
edition of Blue Promise.
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