#Barak Richman

[ethtropy]

Users, not some #AI program, should determine what they see in #Social #Media. Fukuyama Francis, Barak Richman and Ashish Goel talk about the #Middleware approach and how it should be used to end #Big #Tech’s #Information #Monopoly. #ForeignAffairs

[stephenmccull]

Telehealth’s Limits: Battle Over State Lines and Licensing Threatens Patients’ Options

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.

Televisits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don’t keep patients from visiting doctors’ offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

Johns Hopkins Medicine in Baltimore, for example, recently scrambled to notify more than 1,000 Virginia patients that their telehealth appointments were “no longer feasible,” said Dr. Brian Hasselfeld, medical director of digital health and telemedicine at Johns Hopkins. Virginia is among the states where the emergency orders are expiring or being rolled back.

At least 17 states still have waivers in effect, according to a tracker maintained by the Alliance for Connected Care, a lobbying group representing insurers, tech companies and pharmacies.

As those rules end, “it risks increasing barriers” to care, said Hasselfeld. Johns Hopkins, he added, hosted more than 1 million televisits, serving more than 330,000 unique patients, since the pandemic began. About 10% of those visits were from states where Johns Hopkins does not operate facilities.

The rollbacks come amid a longer and larger debate over states’ authority around medical licensing that the pandemic — with its widespread adoption of telehealth services — has put front and center.

“Consumers don’t know about these regulations, but if you all of a sudden pull the rug out from these services, you will definitely see a consumer backlash,” said Dr. Harry Greenspun, chief medical officer for the consultancy Guidehouse.

Still, finding a way forward pits high-powered stakeholders against one another, and consumers’ input is likely to be muted.

State medical boards don’t want to cede authority, saying their power to license and discipline medical professionals boosts patient safety. Licensing is also a source of state revenue.

Providers have long been split on whether to change cross-state licensing rules. Different state requirements — along with fees — make it cumbersome and expensive for doctors, nurses and other clinicians to get licenses in multiple states, leading to calls for more flexibility. Even so, those efforts have faced pushback from within the profession, with opposition from other clinicians who fear the added competition that could come from telehealth could lead to losing patients or jobs.

“As with most things in medicine, it’s a bottom-line issue. The reason telehealth has been blocked across state lines for many years related fundamentally to physicians wanting to protect their own practices,” said Greenspun.

But the pandemic changed the equation.

Even though the initial spike in telehealth visits has eased, utilization remains 38 times higher than before the pandemic, attracting not only patients, but also venture capitalists seeking to join the hot business opportunity, according to a report from consulting firm McKinsey and Co.

Patients’ experience with televisits coupled with the growing interest by investors is focusing attention on this formerly inside-baseball issue of cross-state licensing.

Greenspun predicts consumers will ultimately drive the solution by “voting with their wallets,” aided by giant, consumer-focused retailers like Amazon and Walmart, both of which in recent months made forays into telemedicine.

In the short term, however, the focus is on both the protections and the barriers state regulations create.

“The whole challenge is to ensure maximum access to health while assuring quality,” said Barak Richman, a Duke University law professor, who said laws and policies haven’t been updated to reflect new technological realities partly because state boards want to hang onto their authority.

Patients and their doctors are getting creative, with some consumers simply driving across state lines, then making a Zoom call from their vehicle.

“It’s not ideal, but some patients say they are willing to drive a mile or two and sit in a parking lot in a private space and continue to get my care,” said Dr. Shabana Khan, director of telepsychiatry at NYU Langone Health’s department of child and adolescent psychiatry and a member of the American Psychiatric Association’s Telepsychiatry Committee. She and other practitioners ask their patients about their locations, mainly for safety reasons, but also to check that they are in-state.

Still, for some patients, driving to another state for an in-person or even a virtual appointment is not an option.

Khan worries about people whose care is interrupted by the changes, especially those reluctant to seek out new therapists or who cannot find any clinicians taking new patients.

Austin Smith hopes that doesn’t happen to him.

After initial treatment for what he calls a “weird flavor of cancer” didn’t help reduce his gastrointestinal stromal tumors, he searched out other experts, landing in a clinical trial. But it was in San Diego and the 28-year-old salesman lives in Phoenix.

Although he drives more than five hours each way every couple of months for treatment and to see his doctors, he does much of his other follow-up online. The only difference is “if I was in person, and I said I was hurting here, the doctor could poke me,” he said.

And if the rules change? He’ll make the drive. “I’ll do anything to beat this,” he said of his cancer.

But will doctors, whose patients have spent the past year or more growing comfortable with virtual visits, also be willing to take steps that could likely involve extra costs and red tape?

To get additional licenses, for instance, practitioners must submit applications in every state where their patients reside, each of which can take weeks or months to process. They must pay application fees and keep up with a range of requirements such as continuing education, which vary by state.

States say their traditional role as overseer ensures that all applicants meet educational requirements and pass background checks. They also investigate complaints and argue there’s an advantage to keeping local officials in charge.

“It’s closer to home,” said Lisa Robin, chief advocacy officer with the Federation of State Medical Boards. “There’s a remedy for residents of the state with their own state officials.”

Doctor groups such as the American Medical Association agree.

Allowing a change that doesn’t put centralized authority in a patient’s home state would raise “serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state,” said then-AMA President-elect Jack Resneck during a congressional hearing in March.

But others want more flexibility and say it can be done safely.

Hasselfeld, at Johns Hopkins, said there is precedent for easing multistate licensing requirements. The Department of Veterans Affairs, for example, allows medical staffers who are properly licensed in at least one state to treat patients in any VA facility.

The Alliance for Connected Care and other advocates are pushing states to extend their pandemic rules. A few have done so. Arizona, for example, made permanent the rules allowing out-of-state medical providers to practice telemedicine for Arizona residents, as long as they register with the state and their home-state license is in good standing. Connecticut’s similar rules have now been stretched until June 2023.

The alliance and others also back legislation stalled in Congress that would temporarily allow medical professionals licensed in one state to treat — either in person or via televisits — patients in any other state.

Because such fixes are controversial, voluntary interstate pacts have gained attention. Several already exist: one each for nurses, doctors, physical therapists and psychologists. Proponents say they are a simple way to ensure state boards retain authority and high standards, while making it easier for licensed medical professionals to expand their geographic range.

The nurses’ compact, enacted by 37 states and Guam, allows registered nurses with a valid license in one state to have it recognized by all the others in the pact.

A different kind of model is the Interstate Physician Licensure Compact, which has been enacted by 33 states, plus the District of Columbia and Guam, and has issued more than 21,000 licenses since it began in 2017, said Robin, of the Federation of State Medical Boards.

While it speeds the paperwork process, it does not eliminate the cost of applying for licenses in each state.

The compact simplifies the process by having the applicant physician’s home state confirm his or her eligibility and perform a criminal background check. If the applicant is eligible, the home state sends a letter of qualification to the new state, which then issues a license, Robin said. Physicians must meet all rules and laws in each state, such as requirements for continuing medical education. Additionally, they cannot have a history of disciplinary actions or currently be under investigation.

“It’s a fairly high bar,” said Robin.

Such compacts — especially if they are bolstered by new legislation at the federal level — could help the advances in telehealth made during the pandemic stick around for good, expanding access to care for both mental health services and medical care across the U.S. “What’s at stake if we get this right,” said Richman at Duke, “is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Telehealth’s Limits: Battle Over State Lines and Licensing Threatens Patients’ Options published first on https://smartdrinkingweb.weebly.com/

[glennlaneeldorado-blog]

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Surprise medical bills continue during coronavirus time, and Congress still misses major points

Surprise medical bills continue during coronavirus time, and Congress still misses major points

Surprise medical bills are the scourge of patients. Getty Images / LdF

Barak Richman, Duke University

I am a health policy scholar who became a patient last year, when I needed a surgical repair to a heart valve. My two identities united the day after my operation, when a congenial woman from the admissions department came to discuss my insurance with me.

Her intent was to make sure I understood…

[kristinsimmons]

Even Republicans Want to Outlaw Surprise Medical Billing

By BOB HERTZ

On  April 3, the Secretary of Health and Human Services, Alex Azar, announced that the federal government would pick up the tab for testing and treating all uninsured Americans for COVID-19.

Azar specifically promised that:

a) hospitals would be paid the same prices they receive for Medicare patients; and

b) hospitals which accept the funds would be barred from sending any additional bills to patients.

Did anyone notice the last detail?  This is a Republican, who is promising to protect the vulnerable.

In the coming months, thousands of COVID-19 patients will be routed through a convoluted web of providers. At various points in their treatment. they will be susceptible to receiving out-of-network care — and the staggering bills that often follow.

COVID-19 patients will rarely have the luxury to choose a network hospital, or lab, or specialist. Often, they will need to be treated at any facility that is still open.

Hospitals will be forced to an all-hands-on-deck approach. Patients may have to stay for weeks, needing labor-intensive staffing and anything but a check in-check out mentality.

A patient can do everything right and still face substantial surprise bills. Take someone who fears that he may have contracted COVID-19. After self-quarantining for a week, he develops severe shortness of breath. His wife rushes him to the nearest in-network emergency room. But he’s actually seen by an out-of-network doctor — who may soon send a hefty bill for the visit. If he needs to visit an out-of-network urgent care center, emergency room, or drive-up testing site, he could face additional out-of-pocket costs. Federal law does not prohibit these providers from balance billing.

Matters get worse if his local in-network hospital is approaching capacity, and he must be sent to a hospital across town with spare beds. If the second hospital is outside his insurance network, he could potentially receive a second surprise bill. A third could come from the ambulance that transfers him — it too might not be in-network, and no one will think to check during a crisis. He could get a fourth surprise bill if his coronavirus tests are sent to an out-of-network lab. And so on.

Usually his insurer will refuse to cover the extra costs, and many of the providers will refuse to negotiate. The bills will go to collection. 

Months later, after media exposure or perhaps a class-action lawsuit, his bill might be dismissed. But that will be too late for his credit score to recover, and it may cause him financial headaches for years.  

Surprise bills are particularly reprehensible during this pandemic, when frightened consumers are forced to either seek health care services or risk transmitting a potentially deadly disease.   

This is an issue that only Washington can fix. Some states have taken steps to protect some of their residents from surprise bills– but this is far from universal. Besides, states are prevented by law from regulating large employer self-funded health plans. If Congress doesn’t act on this, nobody can.

(However. Gov. Ned Lamont of Connecticut did recently announce a superb executive order…)

Here is what we must demand:

During an epidemic, all hospitals and all doctors have to be available without extra charges. Providers cannot be allowed to bill for more than the patient’s network fee schedule allows.

For example, if a patient’s Aetna policy pays $4,000 a day for ICU care at a network hospital, then the charge will also be $4,000 if the patient must use a different non-network facility.

Needless to say, all doctors who practice in a network facility can only bill at network rates. This will regulate the conduct of physicians—especially the ones patients don’t choose themselves. Not coincidentally, surprise bills come far more often from ER doctors, anesthesiologists, radiologists, and pathologists than from cardiologists or internists..

Support for this kind of patient protection is non-partisan. In fact, the conservative Heritage Foundation, has proposed the following laws:

 First, Congress should require healthcare providers to supply a good-faith estimate of the cost of scheduled medical care before it occurs, unless the patient declines an estimate. Providers that refuse to supply an estimate before providing care should not be able to “balance bill” afterward.

 Second, Congress should protect consumers against false and misleading information by establishing penalties for any insurer that falsely represents a facility as being in-network, and for any facility that presents itself as being in-network if doctors balance-bill for services they provide at that facility.

Third, Congress should use existing regulations to ban balance billing for non-network emergency care.

In these limited, emergency situations, Congress should require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Actually, we came close to having reform last fall. As described by Daniel Block in the April-May-June issue of Washington Monthly, House and Senate committees announced a deal to at least limit surprise bills on December 8. The insurance industry endorsed it. So did consumer advocates. The White House quickly signaled support and pushed for its inclusion in a must-pass December 20 spending package.

But over the next 48 hours, hospitals and doctors’ groups came out against the proposal. In the Senate, Minority Leader Chuck Schumer reportedly signaled that he was uncomfortable pushing forward with the bill. Richard Neal and Kevin Brady, the top Democrat and Republican on the powerful House Ways and Means Committee, put out their own surprise billing proposal. It was a classic legislative maneuver designed to derail progress.

It succeeded. Congress did nothing. The December 20 deadline came and went.

Again in March, with the huge CARES Act being formed, surprise billing could have been stopped.

But the day before the CARES vote, word spread among lawmakers and lobbyists: Despite an active push, surprise billing reform language had not made it into the final version of the Act.

“Let’s be clear about what is happening,” Jon Walker of The Intercept has tweeted. “Democrats pretend they want to improve healthcare and when they have a chance they take the side of wealthy for-profit companies with the most ghoulish business practices imaginable.”

Actually, acccording to some legal scholars,  we should not even need new legislation. Surprise billing is already illegal, they claim, and states’ attorneys generals could be invalidating those bills right now.

A superb summary appeared in the American Journal of Managed Care — April 2017 – 

Our key motivation is that mutual assent is at the core of commercial transactions. Chargemaster and out-of-network prices, in contrast, are prices that neither patients nor payers accepted in advance nor are they prices to which payers would ever assent.  Instead, the law entitles providers, as one court ruled, to “the average amount that [the provider] would have accepted as full payment from third-party payers such as private insurers and federal healthcare programs.” The law therefore entitles providers to collect no more than prevailing negotiated market prices for any OON services.

Providers have no legal authority to collect charges that exceed market prices for OON services, and thus neither patients nor payers are under any obligation to pay such chargemaster prices. Consistent efforts to enforce this interpretation of contract law would go far in addressing abuses. Moreover, judges, public law enforcement officials, and private attorneys can use this interpretation to combat abusive or harassing efforts that providers pursue to collect such charges. And, perhaps most important, payers that form narrow provider networks can be confident that they will not have to pay extortive prices if their insureds require emergency OON care.                

Billing patients for prices that they did not agree to—prices that no one would ever agree to—and then demanding payment, often through collection services, is abusive.

We reviewed contract law and examined the law’s handling of cases where prices have not been specified in advance, which are the controlling authority to guide courts in disputes over surprise and out of network billing problems, and found that providers have no real legal authority to collect inflated bills, Courts are divided in their rulings on this issue, not because they disagree with our legal analysis, but because they don’t understand how medical bills really work.

We urge state attorneys general to challenge provider claims for charges on behalf of vulnerable patients.  Patients and their attorneys can also challenge these claims directly, without waiting for delayed and cumbersome legislations or regulations. Courts can also support judges administratively to help them reach a reasonable and uniform definition of ’market price’ for their jurisdiction that would end these practices immediately.

For more details, see:

Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care. Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD

Conclusion

Surprise billing is generally not a problem with Medicare or Medicaid.

But for others under age 65, we need new regulations which must be non-negotiable. State health departments must be empowered to cancel overcharges, which will still occur despite regulations.

If we can establish reforms now, in a time of crisis, the new laws have a chance to be permanent when the crisis is over. For now, we must:

Immediately ban providers from sending balance bills for out-of-network health care services related to the coronavirus.

Require insurers to make a payment for these services on a timely basis and limit the patient’s responsibility to in-network cost-sharing or no cost-sharing to the extent that is required under other emergency provisions. In addition, plans would apply in-network deductibles and maximum out-of-pocket limits to health care services related to the coronavirus.

Create a payment standard, based on Medicare rates, to specify the amount owed by the insurer to the out-of-network provider.

Bob Hertz is a retired insurance broker. He learned about health care from Uwe Reinhardt, Joseph White, Dr. Robert Evans, and George Halvorson a fellow Minnesotan.

The post Even Republicans Want to Outlaw Surprise Medical Billing appeared first on The Health Care Blog.

Even Republicans Want to Outlaw Surprise Medical Billing published first on https://wittooth.tumblr.com/

[lauramalchowblog]

Even Republicans Want to Outlaw Surprise Medical Billing

By BOB HERTZ

On  April 3, the Secretary of Health and Human Services, Alex Azar, announced that the federal government would pick up the tab for testing and treating all uninsured Americans for COVID-19.

Azar specifically promised that:

a) hospitals would be paid the same prices they receive for Medicare patients; and

b) hospitals which accept the funds would be barred from sending any additional bills to patients.

Did anyone notice the last detail?  This is a Republican, who is promising to protect the vulnerable.

In the coming months, thousands of COVID-19 patients will be routed through a convoluted web of providers. At various points in their treatment. they will be susceptible to receiving out-of-network care — and the staggering bills that often follow.

COVID-19 patients will rarely have the luxury to choose a network hospital, or lab, or specialist. Often, they will need to be treated at any facility that is still open.

Hospitals will be forced to an all-hands-on-deck approach. Patients may have to stay for weeks, needing labor-intensive staffing and anything but a check in-check out mentality.

A patient can do everything right and still face substantial surprise bills. Take someone who fears that he may have contracted COVID-19. After self-quarantining for a week, he develops severe shortness of breath. His wife rushes him to the nearest in-network emergency room. But he’s actually seen by an out-of-network doctor — who may soon send a hefty bill for the visit. If he needs to visit an out-of-network urgent care center, emergency room, or drive-up testing site, he could face additional out-of-pocket costs. Federal law does not prohibit these providers from balance billing.

Matters get worse if his local in-network hospital is approaching capacity, and he must be sent to a hospital across town with spare beds. If the second hospital is outside his insurance network, he could potentially receive a second surprise bill. A third could come from the ambulance that transfers him — it too might not be in-network, and no one will think to check during a crisis. He could get a fourth surprise bill if his coronavirus tests are sent to an out-of-network lab. And so on.

Usually his insurer will refuse to cover the extra costs, and many of the providers will refuse to negotiate. The bills will go to collection. 

Months later, after media exposure or perhaps a class-action lawsuit, his bill might be dismissed. But that will be too late for his credit score to recover, and it may cause him financial headaches for years.  

Surprise bills are particularly reprehensible during this pandemic, when frightened consumers are forced to either seek health care services or risk transmitting a potentially deadly disease.   

This is an issue that only Washington can fix. Some states have taken steps to protect some of their residents from surprise bills– but this is far from universal. Besides, states are prevented by law from regulating large employer self-funded health plans. If Congress doesn’t act on this, nobody can.

(However. Gov. Ned Lamont of Connecticut did recently announce a superb executive order…)

Here is what we must demand:

During an epidemic, all hospitals and all doctors have to be available without extra charges. Providers cannot be allowed to bill for more than the patient’s network fee schedule allows.

For example, if a patient’s Aetna policy pays $4,000 a day for ICU care at a network hospital, then the charge will also be $4,000 if the patient must use a different non-network facility.

Needless to say, all doctors who practice in a network facility can only bill at network rates. This will regulate the conduct of physicians—especially the ones patients don’t choose themselves. Not coincidentally, surprise bills come far more often from ER doctors, anesthesiologists, radiologists, and pathologists than from cardiologists or internists..

Support for this kind of patient protection is non-partisan. In fact, the conservative Heritage Foundation, has proposed the following laws:

 First, Congress should require healthcare providers to supply a good-faith estimate of the cost of scheduled medical care before it occurs, unless the patient declines an estimate. Providers that refuse to supply an estimate before providing care should not be able to “balance bill” afterward.

 Second, Congress should protect consumers against false and misleading information by establishing penalties for any insurer that falsely represents a facility as being in-network, and for any facility that presents itself as being in-network if doctors balance-bill for services they provide at that facility.

Third, Congress should use existing regulations to ban balance billing for non-network emergency care.

In these limited, emergency situations, Congress should require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Actually, we came close to having reform last fall. As described by Daniel Block in the April-May-June issue of Washington Monthly, House and Senate committees announced a deal to at least limit surprise bills on December 8. The insurance industry endorsed it. So did consumer advocates. The White House quickly signaled support and pushed for its inclusion in a must-pass December 20 spending package.

But over the next 48 hours, hospitals and doctors’ groups came out against the proposal. In the Senate, Minority Leader Chuck Schumer reportedly signaled that he was uncomfortable pushing forward with the bill. Richard Neal and Kevin Brady, the top Democrat and Republican on the powerful House Ways and Means Committee, put out their own surprise billing proposal. It was a classic legislative maneuver designed to derail progress.

It succeeded. Congress did nothing. The December 20 deadline came and went.

Again in March, with the huge CARES Act being formed, surprise billing could have been stopped.

But the day before the CARES vote, word spread among lawmakers and lobbyists: Despite an active push, surprise billing reform language had not made it into the final version of the Act.

“Let’s be clear about what is happening,” Jon Walker of The Intercept has tweeted. “Democrats pretend they want to improve healthcare and when they have a chance they take the side of wealthy for-profit companies with the most ghoulish business practices imaginable.”

Actually, acccording to some legal scholars,  we should not even need new legislation. Surprise billing is already illegal, they claim, and states’ attorneys generals could be invalidating those bills right now.

A superb summary appeared in the American Journal of Managed Care — April 2017 – 

Our key motivation is that mutual assent is at the core of commercial transactions. Chargemaster and out-of-network prices, in contrast, are prices that neither patients nor payers accepted in advance nor are they prices to which payers would ever assent.  Instead, the law entitles providers, as one court ruled, to “the average amount that [the provider] would have accepted as full payment from third-party payers such as private insurers and federal healthcare programs.” The law therefore entitles providers to collect no more than prevailing negotiated market prices for any OON services.

Providers have no legal authority to collect charges that exceed market prices for OON services, and thus neither patients nor payers are under any obligation to pay such chargemaster prices. Consistent efforts to enforce this interpretation of contract law would go far in addressing abuses. Moreover, judges, public law enforcement officials, and private attorneys can use this interpretation to combat abusive or harassing efforts that providers pursue to collect such charges. And, perhaps most important, payers that form narrow provider networks can be confident that they will not have to pay extortive prices if their insureds require emergency OON care.                

Billing patients for prices that they did not agree to—prices that no one would ever agree to—and then demanding payment, often through collection services, is abusive.

We reviewed contract law and examined the law’s handling of cases where prices have not been specified in advance, which are the controlling authority to guide courts in disputes over surprise and out of network billing problems, and found that providers have no real legal authority to collect inflated bills, Courts are divided in their rulings on this issue, not because they disagree with our legal analysis, but because they don’t understand how medical bills really work.

We urge state attorneys general to challenge provider claims for charges on behalf of vulnerable patients.  Patients and their attorneys can also challenge these claims directly, without waiting for delayed and cumbersome legislations or regulations. Courts can also support judges administratively to help them reach a reasonable and uniform definition of ’market price’ for their jurisdiction that would end these practices immediately.

For more details, see:

Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care. Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD

Conclusion

Surprise billing is generally not a problem with Medicare or Medicaid.

But for others under age 65, we need new regulations which must be non-negotiable. State health departments must be empowered to cancel overcharges, which will still occur despite regulations.

If we can establish reforms now, in a time of crisis, the new laws have a chance to be permanent when the crisis is over. For now, we must:

Immediately ban providers from sending balance bills for out-of-network health care services related to the coronavirus.

Require insurers to make a payment for these services on a timely basis and limit the patient’s responsibility to in-network cost-sharing or no cost-sharing to the extent that is required under other emergency provisions. In addition, plans would apply in-network deductibles and maximum out-of-pocket limits to health care services related to the coronavirus.

Create a payment standard, based on Medicare rates, to specify the amount owed by the insurer to the out-of-network provider.

Bob Hertz is a retired insurance broker. He learned about health care from Uwe Reinhardt, Joseph White, Dr. Robert Evans, and George Halvorson a fellow Minnesotan.

The post Even Republicans Want to Outlaw Surprise Medical Billing appeared first on The Health Care Blog.

Even Republicans Want to Outlaw Surprise Medical Billing published first on https://venabeahan.tumblr.com

[toldnews-blog]

New Post has been published on https://toldnews.com/health/curbing-surprise-medical-bills-draws-rare-bipartisan-interest/

Curbing surprise medical bills draws rare bipartisan interest

This story is from Kaiser Health News

Surrounded by patients who told horror stories of being stuck with hefty bills, President Donald Trump recently waded into a widespread health care problem for which almost everyone — even those with insurance — is at risk: surprise medical billing.

Trump’s declaration that taming unexpected bills would be a top priority for his administration echoed through the halls of Congress, where a handful of Republican and Democratic lawmakers have been studying the problem the past couple of years.

The sudden presidential interest has lawmakers on both sides of the aisle expressing optimism about attacking a problem that has affected 57 percent of American adults, according to a University of Chicago survey conducted last summer. Sen. Lamar Alexander, the Tennessee Republican who chairs the influential Health, Education, Labor and Pensions Committee, recently told reporters that he expects to see surprise billing legislation “in the next several months.”

Alexander is encouraged by the movement on both sides of the aisle, said a committee spokesman — giving a particular nod to the efforts of Sen. Bill Cassidy (R-La.). “The chairman looks forward to reviewing their work and hopes it leads to a bipartisan consensus on how to address the issue,” the spokesman added.

“Indications in Congress have always been that this would be something they could do on a bipartisan basis,” said Paul Ginsburg, a health economist at the Brookings Institution, a D.C.-based think tank.

Attention to this practice, which involves charging patients for care that is more expensive than anticipated or not covered by their insurance, has grown following an ongoing Kaiser Health News-NPR “Bill of the Month” investigation into medical billing at large.

While appetite for policymaking is on the upswing, the details of a possible solution remain up in the air.

The Trump administration has not laid out precisely how it would take on surprise bills. But key lawmakers, including Alexander and Cassidy, have met with administration officials to discuss how to reduce health care costs.

With an eye toward drafting legislation, these two senators and several others have been consulting with billing experts, as well as state and local officials, about the biggest challenges and most promising approaches being used around the country.

And, though Senate Majority Leader Mitch McConnell (R-Ky.) has yet to address the issue, House Speaker Nancy Pelosi (D-Calif.) said it would be a priority.

“Ending surprise billing is an important part of Democrats’ ongoing effort to lower out-of-pocket health costs, and we’ll be working on it in the coming Congress,” said Henry Connelly, a Pelosi spokesman.

Previously introduced bills would impose new notification requirements, as well as limitations on what doctors and hospitals might charge patients. They would regulate bills for either emergency care at an out-of-network facility, or non-emergency care when the facility is in-network but the doctor is not.

A draft bill pushed by Cassidy — a gastroenterologist by trade and the leader of a small, bipartisan group of senators studying the issue — would cap what patients pay, and prohibit balance billing, when a patient is expected to make up the difference between what the provider charged and what the insurer paid. Instead of arbitration, the state would set the amount a health plan must pay. In the absence of a local policy, health plans would default to a federal formula outlined in the bill. (This is similar to laws passed in California and Connecticut.)

(MORE: Parents who don’t vaccinate kids tend to be affluent, better educated, experts say)

A bill from Sen. Maggie Hassan (D-N.H.) would tackle the issue by preventing a hospital, physician group or other medical provider from charging patients more for an emergency procedure than they would have expected to pay for in-network care. It would then establish an arbitration process to determine what the patient’s health plan should pay. (This is similar to laws passed in New York and New Jersey.) A bill from Rep. Lloyd Doggett (D-Texas), the chairman of the House Ways and Means’ health subcommittee, introduced during the last Congress with Sen. Sherrod Brown (D-Ohio), would require hospitals to notify patients whether they, and the doctors and other providers the patient would see there, are in-network, as well as how much patients could expect to pay out-of-pocket. Without at least 24 hours’ notice and the patient’s consent — or if the patient was receiving same-day, emergency treatment — the hospital would be able to charge the patient no more than an in-network provider would.

To draw attention to the issue, Hassan planned to bring a guest to Tuesday’s State of the Union address who was billed more than $1,600 for a trip to an in-network emergency room. The patient learned after the fact that the doctor she briefly saw there was out-of-network.

“There does seem to be across-the-board understanding that what’s happening to patients right now isn’t right or fair,” Hassan told KHN.

Other members of Congress, including Sen. Amy Klobuchar (D-Minn.) and Sen. Tammy Baldwin (D-Wis.), will bring guests with painful, personal stories regarding the high cost of prescription drugs.

For its part, the administration says its commitment to addressing surprise medical bills is firm.

“President Trump has identified surprise medical bills as a serious concern of the administration. Protecting patients from these outrageous and unexpected bills and charges is a top priority for Secretary [Alex] Azar,” said Caitlin Oakley, a Department of Health and Human Services spokeswoman.

Hassan said she has not heard anything from the White House. But as Congress shifts its focus away from the partial government shutdown, she predicted, surprise billing could emerge as a legislative priority, adding that she and Cassidy have coordinated on the issue.

Both Hassan’s and Cassidy’s bills “would go a long way toward protecting patients,” suggested Zack Cooper, a Yale health economist who researches surprise billing. Hassan’s legislation, he said, has the additional benefit of likely bringing down health care costs.

“There are a lot of issues that can’t be fixed or at least can’t be fixed easily. This is an issue that causes immense pain and is quite visceral and can be fixed,” Cooper said.

And federal legislation is likely necessary, experts say. Some states have passed laws meant to curb surprise billing, and to protect patients from the costs — but those laws don’t affect self-insured large employers, which fall under federal jurisdiction and affect more than 60 percent of people who get insurance through work.

The presidential bully pulpit could be hugely influential — in particular, Ginsburg suggested, by “leaning on Congress” to bring legislation to Trump’s desk.

And new legislation probably is the most effective vehicle, health policy experts said. It’s unclear whether or what kind of executive action HHS could take without Congress.

“Some creative lawyers could come up with creative interpretations [of existing laws] and lead to smart policy,” said Barak Richman, a Duke University law school professor who focuses on health policy.

But re-interpreting federal law would almost certainly invite legal challenges, he added.

Already, competing industry groups are lobbying to put their stamp on any federal policy. The emergency physicians’ trade group has backed an approach like Hassan’s, while the insurance lobby is calling for a Cassidy-style bill. When asked about the industry’s response, Hassan said she has gotten “a variety of feedback — as you would expect.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

[dinafbrownil]

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

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Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-d28db32c2c1a6dafd7b981b01ad671b4') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-d28db32c2c1a6dafd7b981b01ad671b4' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

( function() { var func = function() { var iframe = document.getElementById('wpcom-iframe-afbe627a12c0b0f2a89cba0270865573') if ( iframe ) { iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-afbe627a12c0b0f2a89cba0270865573' }, "https:\/\/embeds.kff.org" ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( 'embeds.kff.org' !== origin.host ) return; // Verify message is in a format we expect if ( 'object' !== typeof e.data || undefined === e.data.msg_type ) return; switch ( e.data.msg_type ) { case 'poll_size:response': var iframe = document.getElementById( e.data._request.frame_id ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( e.data.height ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify's website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

from Updates By Dina https://khn.org/news/one-defensive-strategy-against-surprise-medical-bills-set-your-own-terms/

[montrealtimes]

A Possible Strategy for Fending Off Surprise Medical Bills

A Possible Strategy for Fending Off Surprise Medical Bills

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” which Barak Richman, who studies contract law and teaches at Duke University Law School, said patients can’t really give because they are…

[rcraft404]

Stateless Commerce: The Diamond Network and the Persistence of Relational Exchange

Stateless Commerce: The Diamond Network and the Persistence of Relational Exchange

In Stateless Commerce, Barak Richman uses the colorful case study of the diamond industry to explore how ethnic trading networks operate and why they persist in the twenty-first century. How, for example, does the 47th Street diamond district in midtown Manhattan―surrounded by skyscrapers and sophisticated financial institutions―continue to thrive as an ethnic marketplace that operates like a…

[kristinsimmons]

Even Republicans Want to Outlaw Surprise Medical Billing

By BOB HERTZ

On  April 3, the Secretary of Health and Human Services, Alex Azar, announced that the federal government would pick up the tab for testing and treating all uninsured Americans for COVID-19.

Azar specifically promised that:

a) hospitals would be paid the same prices they receive for Medicare patients; and

b) hospitals which accept the funds would be barred from sending any additional bills to patients.

Did anyone notice the last detail?  This is a Republican, who is promising to protect the vulnerable.

In the coming months, thousands of COVID-19 patients will be routed through a convoluted web of providers. At various points in their treatment. they will be susceptible to receiving out-of-network care — and the staggering bills that often follow.

COVID-19 patients will rarely have the luxury to choose a network hospital, or lab, or specialist. Often, they will need to be treated at any facility that is still open.

Hospitals will be forced to an all-hands-on-deck approach. Patients may have to stay for weeks, needing labor-intensive staffing and anything but a check in-check out mentality.

A patient can do everything right and still face substantial surprise bills. Take someone who fears that he may have contracted COVID-19. After self-quarantining for a week, he develops severe shortness of breath. His wife rushes him to the nearest in-network emergency room. But he’s actually seen by an out-of-network doctor — who may soon send a hefty bill for the visit. If he needs to visit an out-of-network urgent care center, emergency room, or drive-up testing site, he could face additional out-of-pocket costs. Federal law does not prohibit these providers from balance billing.

Matters get worse if his local in-network hospital is approaching capacity, and he must be sent to a hospital across town with spare beds. If the second hospital is outside his insurance network, he could potentially receive a second surprise bill. A third could come from the ambulance that transfers him — it too might not be in-network, and no one will think to check during a crisis. He could get a fourth surprise bill if his coronavirus tests are sent to an out-of-network lab. And so on.

Usually his insurer will refuse to cover the extra costs, and many of the providers will refuse to negotiate. The bills will go to collection. 

Months later, after media exposure or perhaps a class-action lawsuit, his bill might be dismissed. But that will be too late for his credit score to recover, and it may cause him financial headaches for years.  

Surprise bills are particularly reprehensible during this pandemic, when frightened consumers are forced to either seek health care services or risk transmitting a potentially deadly disease.   

This is an issue that only Washington can fix. Some states have taken steps to protect some of their residents from surprise bills– but this is far from universal. Besides, states are prevented by law from regulating large employer self-funded health plans. If Congress doesn’t act on this, nobody can.

(However. Gov. Ned Lamont of Connecticut did recently announce a superb executive order…)

Here is what we must demand:

During an epidemic, all hospitals and all doctors have to be available without extra charges. Providers cannot be allowed to bill for more than the patient’s network fee schedule allows.

For example, if a patient’s Aetna policy pays $4,000 a day for ICU care at a network hospital, then the charge will also be $4,000 if the patient must use a different non-network facility.

Needless to say, all doctors who practice in a network facility can only bill at network rates. This will regulate the conduct of physicians—especially the ones patients don’t choose themselves. Not coincidentally, surprise bills come far more often from ER doctors, anesthesiologists, radiologists, and pathologists than from cardiologists or internists..

Support for this kind of patient protection is non-partisan. In fact, the conservative Heritage Foundation, has proposed the following laws:

 First, Congress should require healthcare providers to supply a good-faith estimate of the cost of scheduled medical care before it occurs, unless the patient declines an estimate. Providers that refuse to supply an estimate before providing care should not be able to “balance bill” afterward.

 Second, Congress should protect consumers against false and misleading information by establishing penalties for any insurer that falsely represents a facility as being in-network, and for any facility that presents itself as being in-network if doctors balance-bill for services they provide at that facility.

Third, Congress should use existing regulations to ban balance billing for non-network emergency care.

In these limited, emergency situations, Congress should require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Actually, we came close to having reform last fall. As described by Daniel Block in the April-May-June issue of Washington Monthly, House and Senate committees announced a deal to at least limit surprise bills on December 8. The insurance industry endorsed it. So did consumer advocates. The White House quickly signaled support and pushed for its inclusion in a must-pass December 20 spending package.

But over the next 48 hours, hospitals and doctors’ groups came out against the proposal. In the Senate, Minority Leader Chuck Schumer reportedly signaled that he was uncomfortable pushing forward with the bill. Richard Neal and Kevin Brady, the top Democrat and Republican on the powerful House Ways and Means Committee, put out their own surprise billing proposal. It was a classic legislative maneuver designed to derail progress.

It succeeded. Congress did nothing. The December 20 deadline came and went.

Again in March, with the huge CARES Act being formed, surprise billing could have been stopped.

But the day before the CARES vote, word spread among lawmakers and lobbyists: Despite an active push, surprise billing reform language had not made it into the final version of the Act.

“Let’s be clear about what is happening,” Jon Walker of The Intercept has tweeted. “Democrats pretend they want to improve healthcare and when they have a chance they take the side of wealthy for-profit companies with the most ghoulish business practices imaginable.”

Actually, acccording to some legal scholars,  we should not even need new legislation. Surprise billing is already illegal, they claim, and states’ attorneys generals could be invalidating those bills right now.

A superb summary appeared in the American Journal of Managed Care — April 2017 – 

Our key motivation is that mutual assent is at the core of commercial transactions. Chargemaster and out-of-network prices, in contrast, are prices that neither patients nor payers accepted in advance nor are they prices to which payers would ever assent.  Instead, the law entitles providers, as one court ruled, to “the average amount that [the provider] would have accepted as full payment from third-party payers such as private insurers and federal healthcare programs.” The law therefore entitles providers to collect no more than prevailing negotiated market prices for any OON services.

Providers have no legal authority to collect charges that exceed market prices for OON services, and thus neither patients nor payers are under any obligation to pay such chargemaster prices. Consistent efforts to enforce this interpretation of contract law would go far in addressing abuses. Moreover, judges, public law enforcement officials, and private attorneys can use this interpretation to combat abusive or harassing efforts that providers pursue to collect such charges. And, perhaps most important, payers that form narrow provider networks can be confident that they will not have to pay extortive prices if their insureds require emergency OON care.                

Billing patients for prices that they did not agree to—prices that no one would ever agree to—and then demanding payment, often through collection services, is abusive.

We reviewed contract law and examined the law’s handling of cases where prices have not been specified in advance, which are the controlling authority to guide courts in disputes over surprise and out of network billing problems, and found that providers have no real legal authority to collect inflated bills, Courts are divided in their rulings on this issue, not because they disagree with our legal analysis, but because they don’t understand how medical bills really work.

We urge state attorneys general to challenge provider claims for charges on behalf of vulnerable patients.  Patients and their attorneys can also challenge these claims directly, without waiting for delayed and cumbersome legislations or regulations. Courts can also support judges administratively to help them reach a reasonable and uniform definition of ’market price’ for their jurisdiction that would end these practices immediately.

For more details, see:

Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care. Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD

Conclusion

Surprise billing is generally not a problem with Medicare or Medicaid.

But for others under age 65, we need new regulations which must be non-negotiable. State health departments must be empowered to cancel overcharges, which will still occur despite regulations.

If we can establish reforms now, in a time of crisis, the new laws have a chance to be permanent when the crisis is over. For now, we must:

Immediately ban providers from sending balance bills for out-of-network health care services related to the coronavirus.

Require insurers to make a payment for these services on a timely basis and limit the patient’s responsibility to in-network cost-sharing or no cost-sharing to the extent that is required under other emergency provisions. In addition, plans would apply in-network deductibles and maximum out-of-pocket limits to health care services related to the coronavirus.

Create a payment standard, based on Medicare rates, to specify the amount owed by the insurer to the out-of-network provider.

Bob Hertz is a retired insurance broker. He learned about health care from Uwe Reinhardt, Joseph White, Dr. Robert Evans, and George Halvorson a fellow Minnesotan.

The post Even Republicans Want to Outlaw Surprise Medical Billing appeared first on The Health Care Blog.

Even Republicans Want to Outlaw Surprise Medical Billing published first on https://wittooth.tumblr.com/

[gordonwilliamsweb]

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

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Subscribe to KHN’s free Morning Briefing.

Sign Up

Please confirm your email address below:

Sign Up

Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

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He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify's website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms published first on https://nootropicspowdersupplier.tumblr.com/

[stephenmccull]

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

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Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

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He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify's website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms published first on https://smartdrinkingweb.weebly.com/