Surprise Medical Bills: Who’s Affected?
Did you receive a surprise medical bill after an emergency room visit or treatment at a hospital?
It’s reasonable to think that if you go to a hospital that is in the network of your health insurance plan that the doctors who treat you at the hospital are also “in-network,” but many patients have learned that this is not the case when surprise medical bills show up at their doors from “out-of-network” doctors.
These surprise bills are known as balance bills because the medical providers charge patients the difference between their out-of-network rates and the amounts paid by insurance, or the “balance.”
Out-of-network doctors seek payment directly from the patients in these types of situations. When a patient believes they received care from an “in-network” hospital, balance billing from an “out-of-network” physician is unexpected, which is why they are referred to as “surprise medical bills.”
As medical care has evolved, large physician staffing companies have been formed, which companies contract with hospitals to staff certain of the hospitals’ departments, such as emergency, radiology and anesthesia. However, these companies are not required to take the same insurance as the hospitals, and neither the hospitals nor the staffing companies typically make an effort to disclose this.
The staffing company then bills the insured patient for the balance between the out-of-network reimbursement they receive, and their own set price. These companies profit by not disclosing their identities, and profit is the primary goal of these companies, as many of them are owned, not by physicians, but by private equity companies, according to an analysis published in the Harvard Business Review.
If you received a medical bill from an out-of-network doctor after being treated at an in-network hospital, you may qualify to file a surprise medical bill lawsuit or class action lawsuit.
The attorneys working with Top Class Actions do not charge any fees for evaluation or litigation as we work on a contingent fee basis, so there are not any out-of-pocket costs to participate.
Learn more by filling out the form on this page or call (877) 370-7703 for a FREE case evaluation.
Surprise Medical Bills: Legislation Around the Country
Surprise medical bills are an issue that has caught the attention of lawmakers, and it has bipartisan support, according to The Wall Street Journal.
Congress has been working on legislation to address the issue of Surprise Medical Bills since at least January 2019 when President Donald Trump said that it was one of his top priorities, but the different versions of the legislation keep stalling in Congress.
California is revisiting this issue, Vox is reporting. California passed legislation to combat surprise medical bills in 2016, but it left an opening in which patients could be charged surprise bills for emergency room visits at out-of-network hospitals.
A California lawmaker has introduced a bill prohibiting hospitals from charging patients any more than their copays or deductibles if they are treated at an out-of-network hospital. This legislation is designed to protect patients in the event that they have an emergency in which they have no control over where they are treated.
The California bill (A.B. 1611) passed in the California Assembly, but it is expected to face some challenges in the Senate.
Legal experts warn that even if it passes and is signed into law that more protections may still be necessary, according to Law360.
The Georgia Senate passed legislation in February 2020 with the goal of limiting surprise medical bills, according to the Atlanta Journal-Constitution. The Georgia legislation specifically addresses patients who go to the hospital who are insured and go to an in-network hospital.
The Texas legislature passed a landmark bill in May 2019 to combat surprise medical bills that Gov. Greg Abbott signed in June that makes it illegal for emergency room doctors to charge patients for the portion of the bill that the insurance company doesn’t cover, according NPR.
In addition, Texas patients will be protected from balance billing by out-of-network doctors when patients don’t have any control over who they are treated by at an in-network hospital. The bill is expected to go into effect in 2020.
The Texas legislation came after significant pressure from outside groups. Texas health insurance companies, business groups, and consumer organizations sent a letter to state lawmakers in February 2019 saying that the Texas legislature needed to address the problem of consumers getting caught in the middle of an issue that is really between insurance companies and healthcare providers, the Houston Chronicle reported.
In Texas, the issue of surprise medical bills became such a problem that it was clogging up the Texas Department of Insurance as consumers are trying to get help from the state with their unexpected medical bills, the Texas Tribune reported.
Surprise Medical Bills Class Action Lawsuits
Several class action lawsuits have been filed by the law firm Wolf Popper LLP in both state and federal courts around the country. Wolf Popper partners, Emily Madoff and Chet Waldman, as well as other Wolf Popper attorneys, have read over 4,000 complaints from Americans who say they were sent large medical bills for a procedure or lab that they didn’t expect to receive, according to Bloomberg Law.
Wolf Popper recently received preliminary approval of a settlement in one of its class actions. The settlement enables those injured by defendants’ alleged unfair and deceptive business practices to make a complete recovery and requires defendants take steps to prevent consumers from being misled in the future.
Waldman himself was denied care when he went to an Ambulatory Surgery Center in New Hyde Park, New York to receive an epidural shot to treat chronic pain, Gothamist reported.
When he was asked to sign the Financial Liability Form, he said that it essentially gave the Center and its anesthesiologists a “blank check,” and he believed that it violated his rights under New York’s surprise billing law that was passed in 2014.
Physicians Sue Anthem Blue Cross Over ER Policy
Anthem/Blue Cross Blue Shield implemented a new ER policy in Georgia in 2017 to review emergency department claims and if they are not what the company believes to be true emergencies, not to approve payment as an emergency visit.
Emergency room doctors in Georgia are taking issue with this policy in a new lawsuit filed on July 17, arguing that the policy needs to end and Anthem needs to cover the costs of any ER claims that it has denied, Becker’s Hospital Review reported.
Why Do Surprise Medical Bills Happen?
Surprise medical bills may happen for a variety of reasons. In some cases, an insurance company may decide that the medical procedure wasn’t really necessary. In many cases, unexpected bills show up from an outside medical group. This happens when the patient goes to an in-network hospital, but the doctors work for a different physician group that isn’t in-network. This scenario can occur in both emergency rooms and planned surgeries.
Insurer Says Emergency Surgery Not an Emergency
A New York man went to his doctor because he was suffering from excruciating back pain. When an MRI showed that he had a herniated disc that if not treated right away could sever his spinal cord, leaving him paralyzed, he was told to go to the emergency room right away, CBS News reported.
He ended up in emergency surgery, which fixed his back, but when he started receiving the medical bills, they added up to more than $650,000.
His insurance company decided that the surgery was not a true emergency and that it was not medically necessary.
The story was featured in a CBS News special titled “Medical Price Roulette” in which they are investigating “the lack of transparency in health care pricing.”
Outside Physician Groups Overcharging for Services
One of the reasons why these out-of-network doctors are working at “in-network” hospitals is because some hospitals contract with outside physician groups (as opposed to individual physicians) to staff and operate their entire emergency departments.
Some industry participants have blamed “private contractors” for the rising cost of ER visits and “skyrocketing” ER bills.
According to these industry participants, because they are not employees of the hospital, such groups use it as an opportunity to charge patients significantly more for their care and in some cases balance bill them for hundreds or thousands of dollars.”
Patients who are getting hit with these surprise medical bills are also being sued by the hospitals who are sending the bills, according to The Washington Post.
A small rural hospital in Missouri has filed more than 1,100 lawsuits against patients because they haven’t paid their hospital bills.
Dr. Ming Lin, a physician who worked at PeachHealth St. Joseph Medical Center in Bellingham, Washington, is an emergency room doctor who was recently fired for blowing the whistle on the safety conditions, lack of supplies, and protective gear for medical personnel. Dr. Lin was employed by a staffing firm the provides ER personnel to hospitals, according to Naked Capitalism.
The outside physician groups are owned by Wall Street investment firms.
“Care of the sick is not the mission of these companies; their mission is to make outsized profits for the private equity firms and its investors,” according to Naked Capitalism. “Overcharging patients and insurance companies for providing urgent and desperately needed emergency medical care is bad enough.”
The firing of Lin highlighted the control that these private equity companies have over healthcare, according to a recent story by NBC News.
Several hospitals, emergency rooms, nursing homes, physician groups, and hospice-care centers are now owned by private equity firms.
Private equity firms are defined as a financial entity that uses funds from investors to purchase companies and later sell them for a profit to another corporation.
Lin explained that before the private equity firm took over his emergency department, his case would have been peer-reviewed, but under the new ownership, there was no right to due process.
“One of the objectives is to point out any deficiencies in the system that may harm the patient,” Lin told NBC News. “Because private equity has taken over health care, it has made that difficult.”
According to NBC News, private equity firms purchased health care companies to the tune of $79 billion in 2019 alone. Over the last 10 years, private companies have spent a total of $340 billion on similar acquisitions.
This represents a major shift in hospitals being owned by non-profit, religious organizations, universities or medical schools, states, and cities to for-profit entities. For-profit hospitals did exist, but they were the exception.
Critics of the change say that if the goal is profits that this can stand in opposition to goal of making the best healthcare decisions for patients and keeping healthcare workers safe.
Surprise Billing for ‘Out-of-Network’ Medical Services at ‘In-Network’ Facilities
Surprise out-of-network bills can occur even when you think you’ve done all your homework to make sure that a hospital you visit is in-network with your insurance company.
One Texas resident experienced this unfortunate problem when he was injured in a violent attack that landed him in the emergency room at Dell Seton Medical Center in Austin, Texas with a broken jaw.
According to an article in Vox article, the patient thought he did his due diligence when he checked on his smartphone to make sure that Dell Seton was in the network of hospitals covered by his health insurance provider Humana.
The patient told Vox that he doesn’t know what he could have done differently. “I couldn’t go home. I had a broken jaw in two places,” he said.
Another Austin resident found himself at a hospital because he had a heart attack and was in need of heart surgery. He double checked to make sure that the hospital he was brought to was covered by his insurance company, Seton Healthcare. He was told that the hospital had accepted his insurance.
He was shocked when he received a bill for more than $108,000. He came to find out that the hospital was not in-network.
A Texas woman ended up with a $36,000 bill after she ended up in the emergency room with a life-threatening emergency. The woman claims that the emergency room and insurance company failed to properly follow insurance regulations in the Lone Star State, the Houston Chronicle reported.
An Ohio man found himself in a similar situation when he ended up at the emergency room after a bicycle accident, Dayton Daily News reported. His family made sure he was at an in-network hospital, which is why they were surprised when he received a $17,000 bill from the plastic surgeon that operated on him, who was “in-network.”
ER doctors, as well as radiologists, anesthesiologists, and some other medical specialties don’t always work directly for the hospital. Instead, they actually may be employees of outside companies, which may not have contracts with the same insurers as the hospital.
According to a Yale study “Surprise! Out-of-Network Billing for Emergency Care in the United States,” patients have an almost 1-in-4 chance that the ER doctor that treats them is out-of-network.
This creates a confusing and costly situation for patients who are trying to go to in-network doctors and hospitals.
Surprise Medical Bills From Planned Surgeries
This type of situation can also happen if someone is going to the hospital for a planned surgery, as described in a story by The New York Times.
A patient may carefully select a doctor who is in-network to their insurance plan and make sure that the hospital where the surgery will take place is also in-network. So, they logically expect that all coverage will, therefore, be at in-network rates.
When it comes time for surgery, however, an anesthesiologist walks in, introduces him or herself, and the surgery begins. Later, the patient receives a bill for anesthesiology services at out-of-network rates. It turns out that the anesthesiologist was an out-of-network provider under the patient’s insurance plan.
The insurance company will only cover the anesthesiologist at an out-of-network rate, and the patient ends up being responsible for the balance. This is also “balance billing.”
To make matters worse, the Yale study found that out-of-network doctors are paid 2.7 times more than in-network doctors, which means the patient ends up paying a higher rate than what they would have paid if the doctor had been in-network.
Financial Impact of Surprise Medical Bills
In some cases, surprise medical bills have left patients with enormous debt and have resulted in liens being placed on patients’ homes or fear of bankruptcy.
A woman wrote in The New York Times that her family received a bill for $145,000 after their child had a scheduled stay in the hospital that the doctors assured her would cost no more than a modest co-pay.
After receiving this bill, the woman says that she “went to bed that night not knowing whether we would have to declare bankruptcy in the morning” because of the enormous debt.
A Colorado woman says that she ended up in the hospital with appendicitis one night, but that before she went to the hospital she called ahead to make sure that the hospital was covered by her insurance, according to NBC News.
She said that she thought that meant that the anesthesiologist, the surgeon, the nurse, and other hospital workers were all covered, as well. She was surprised when she received a bill from the surgeon for $4,727.
After declining to pay the bill, she ended up with a lien on her house from the collection agency.
ER Doctors Want Surprise ER Bills to End
The American College of Emergency Physicians (ACEP) has put together a six-point proposal for addressing the issue of surprise emergency room bills. At the center of its proposal is taking the “patient out of the middle” of disputes between insurance companies and healthcare providers.
The ACEP’s proposed plan includes the following:
- Ending balance billing
- Insurers only pay in-network prices for ER care
- Insurers will pay copay to the hospital directly, making the insurer the single point of contact for the patient
- Disclosure of patient’s deductible on insurance cards
- Clear explanation of benefits provided to patients by insurers
“Patients can’t choose where and when they will need emergency care—so they should not be punished financially for having emergencies,” the ACEP stated in its plan.
Join a Free Surprise Medical Bill Class Action Lawsuit Investigation
Patients who received a surprise medical bill may be able to join a class action lawsuit.
Unfortunately, most large companies that hire physicians to work in the various hospitals do not bill under their names—they generally bill under the name of the physician group for that hospital—so it can be difficult to determine if you went to an emergency room run by a large company.
The attorneys handling this class action investigation can help you determine your eligibility. Simply fill out the form on this page for a free evaluation.
If you were hit with a surprise medical bill from an out-of-network doctor at an in-network hospital, you may qualify to join this surprise medical bill class action lawsuit investigation.
Get help now by filling out the form on this page or call (877) 370-7703 for a FREE case evaluation.
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