Posted on 07/21/2015 4:26:11 AM PDT by markomalley
Sallyann Johnson considers herself a pretty savvy health care consumer. When she fell and injured her hands and wrists, she didn’t head for an expensive emergency room, choosing an urgent care clinic near her Milwaukee home instead.
Before seeking treatment, she asked the key question: Did the center accept her insurance? Yes, Johnson was assured, both on the phone and then again when she arrived at the clinic.
After X-rays and a visit with a physician assistant, Johnson learned her wrists were sprained, but weeks later, it was her wallet that sustained the most damage.
“I received a bill from a doctor for $356,” said Johnson, 62. “I felt I asked all the right questions. I even re-asked the questions.”
Long seen as a lower-cost alternative to hospital emergency rooms for minor illnesses or injuries, urgent care centers are increasingly popular with consumers – and their insurers.
But like doctors and hospital ERs, urgent care can also present payment headaches if they are not part of a patient’s insurance network. And consumers may need to ask specifically about network participation to find out.
Earlier this month, the New York State attorney general wrote businesses that operate dozens of urgent care clinic locations, saying the health plan participation information on their websites may be “deceptive” and asking for specific information about which insurance plans they participate in as in-network partners. The inquiries went to stand-alone clinics, as well as those affiliated with hospital systems and retail outlets, including Duane Reade and CVS stores.
In New York and nationally, insurance coverage information provided on urgent care clinic websites is often unclear. Some centers’ websites say they “accept most major insurance plans” while others list specific insurers they “accept,” or “work with” or “bill.” But what does that mean?
Accepting insurance might mean a consumer will owe the balance between what the clinic charges and what an insurer pays toward an out-of-network visit, which is generally far less than payment for an in-network provider.
Such statements “may lead consumers to believe that an out-of-network urgent care center is … ‘in network’ with their health plan,” say the July 2 letters from N.Y. Attorney General Eric T. Schneiderman.
The centers may well be in-network with some insurers. But if they’re not, “consumers may receive unexpected, and often costly, bills … when they believed that they would be responsible solely for their copayment …,” the letters say.
A spokesman for Walgreens, owner of Duane Reade stores, said the company is reviewing the attorney general’s letter but would not comment further. The industry’s trade group, the Urgent Care Association of America, would not comment directly on the letters, but in a statement said it “encouraged members to be as clear and transparent as possible regarding billing matters.”
In March, one of the broadest laws in the country concerning out-of-network bills went into effect in New York, imposing new requirements on hospitals, doctors and other medical providers who send so called “surprise bills” to insured consumers. As a result, insured patients will, in most cases, see their payments limited if treatment was provided at an in-network facility, but by out-of-network providers. The New York law also requires most health groups and facilities to disclose in writing or on their websites the names of the health plans with whom they participate. Regulations issued don’t specifically mention how the law will apply to urgent care centers.
Surprise bills, also known as “balance bills,” are part of the complex way that health care is paid for in the U.S. Insurers form networks as one way to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees. Out-of-network hospitals and doctors can set their own fees and “balance bill” patients for the portion insurers don’t cover.
Some patients choose to go out of network because they want a specific doctor or hospital. But, as insurers shrink networks, some patients may be unable to find an in-network provider. And others may get a balance bill after choosing an in-network hospital, only to learn later that the anesthesiologist or the lab were not included in their insurer’s network. Balance bills can run into thousands of dollars.
While the problem predates the Affordable Care Act, the president’s signature health care law largely sidesteps the issue. It says only that insurers must not charge policyholders higher copayments for emergency department services at non-network hospitals because patients often can’t choose where they go. Medicare, however, strictly limits how much patients can be balance billed by doctors who don’t participate in the program.
Other than for emergency care, though, relatively few states have addressed balance billing, mainly because solutions are difficult and generally pit powerful rivals — hospitals, doctors and insurers — against one another.
Blake Hutson, the interim director of health reform at Consumers Union, applauded the New York attorney general’s action, adding that more clarity is needed to help patients determine whether an urgent care clinic and its staff are part of their health plan. While it’s hard to know how common the problem is, Hutson said, “if we’re seeing it in New York, we’re probably seeing it in other states, too.”
The key question to ask when calling an urgent care center, Hutson said, is not whether it accepts your insurance, but whether it participates in your insurance plan.
Even then, as Johnson in Milwaukee learned, you might still get billed. In her case, the urgent care center was in network. But the doctor group overseeing the care was not. Hence the $356 bill, which Johnson paid. Even her insurer was surprised, she said.
“They also didn’t know that all the doctors were subcontracted,” she said.
362 dollars is not a big bill......and an ER visit for that would probably be 4X that much. BS Headline.
People have to be wary anytime they accept “services”, and fight anything on a bill that seems out of place. A friend was taken by ambulance to the ER, and was presented with numerous bills from various sources. In the end, several hundred dollars were removed from one bill because the ambulance ride was a service for residents of her municipality (as part of their property taxes), and one bill from a “paramedic” on the ambulance was tossed altogether - it was as though they tried to treat him as an additional doctor who was billed separately from the ER staff.
Lots of questionable bills involved, apparently to prop up medical companies in serious financial trouble.
Do you expect to pay a lot more than you were quoted after you get a quote from an auto repair shop?
The story does not go there, other than to say she was told her insurance would cover it. And maybe her insurance DID cover it, but subject to deductibles and co pays, etc. And then the article went into generalities, and since most reporters and certainly most patients don't know anything about insurance to begin with.
And then there's the part of the headline.."Just Like ER" - and at 356, it ain't just like the ER....so in conclusion, I'm not saying the doc in a box did, or did not, act properly. I'm just saying it is not just like the ER.
$356.00?If this woman went to her local emergency room or trauma center it would have cost three times as much.
I had an MRI done in a non- hospital facility and it cost me $1500.00.
Its only going to get worse unless congress kills obamacare.
Apparently she was wrong.
I thought the exact same thing.
If she blew a tire she’d pay $350 or more
Stuff happens
I don’t get why people are so averse to paying out of pocket for fairly minor health issues and I can’t believe someone spun this into a story
You don’t ask the doctor if they accept insurance, you ask insurance if they accept the doctor.
“But like doctors and hospital ERs, urgent care can also present payment headaches if they are not part of a patient’s insurance network. And consumers may need to ask specifically about network participation to find out.”
Unfortunately, Urgent Care is closer to hospital costs than to your normal doctors costs. Also, insurance companies do not recognize urgent care like they do a hospital, so where she would have paid $100 at the hospital and gone 90/10 or even 0 because of deductible waived, she has to pick up the deductible at urgent care.
It's because people have been trained that healthcare is "free" - when of course it isn't, can't be, and never has been. Back in the day, not that many years ago, we had what was called major medical....insurance that protected you from "the big one" - but didn't bureaucratize all the "small ones." It was MUCH more efficient.
The irony is, if she'd just offered to pay cash and save all the insurance paperwork, the bill would have been maybe half of what it was.
So if I read you right (and I may not have) - you think what she should have done was go the route that would continue to feed the lie in her brain that health care is free.
Isn’t that belief what got us into this Obamacare mess in the first place?
I have nothing but good things to say about the Urgent Care
Center I used several times. I got operated on (minor) and the wound packed, pain meds and antibiotics all for $400.
I trust them much more than my local hospital. I hope everyone corrects the nurses about the way they take blood pressure though. The standard way for years was sitting with feet on the floor and arm on the table. Now they try to take your blood pressure sitting on the edge of a gurney with your feet hanging down and your arm hanging down. This new wrong way bumps your blood pressure.
Are you paying for those who aren’t asked to pay?
Not sure if you read me correctly there. My point is Urgent Care is a suckers bet. I get the flu, I go to my doctor, it is a $25 co-pay in network. I go to urgent care for the same thing, my co-pay is $75.
Urgent Care is the convenience store of the medical world and that is how insurance companies are treating it. If urgent care facilities can compete for business, costs would come down to doctors prices.
“My point is Urgent Care is a suckers bet. I get the flu, I go to my doctor, it is a $25 co-pay in network. I go to urgent care for the same thing, my co-pay is $75.”
No, you call your doctor and get an appointment to see him in two weeks.
For 35 years, our HMO covered everything but the co-pay and piddly stuff. Now that we need it, they want $6k off the top and then they’ll chip in a little which is less than our monthly premiums. Why do we even have insurance?
They balance billed her. While in network providers are bound by contract to accept a certain rate from Insurance and NOT bill the patient over that amount, out of network providers are not. So, while an OON provider may, in fact, accept your insurance payment of $200 for a $500 bill, it is also perfectly acceptable for them to bill you the remaining $300. That is standard in the industry. An in network provider is bound by contract to accept a certain rate for services rendered, and NOT balance billed bill the patient.
I don’t think thats it.
The woman had insurance, was paying premiums and deductables. There’s a legitimate expectation that if you are paying for something, you’re going to get what you pay for.
It doesn’t remove the caveat emptor element of knowing what you are buying, but it sure looks to me like a lot of insurance companies and healthcare providers are setting up scams where they create the appearance of someting (in this case being in-network providers when they aren’t) knowing that they can then throw additional charges on their customer and the customer will either just pay or will ecounter so much bureaucratic morass in trying to fight the additional bills that they’ll give up.
Of course the key here is that this “informed consumer” clearly wasn’t. We keep a list of local in-network providers, including urgent care centers on hand. When we travel we put together such lists beforehand for both out destination and travel routes. This is, now, just procactive common sense. As is knowing that the key question to ask before receiving services is “are you in my network?”
But that also doesn’t excuse the con-job a lot of places are currently doing on consumers.
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