It’s easy to understand why someone with health insurance gets frustrated with an unexpected bill for dozens or even thousands of dollars from a physician, hospital or medical provider.
“Why did I get this bill?” the patient asks. “I have insurance. I’m covered!”
People receive surprise bills because that’s what their insurance companies want to happen.
It’s part of their business plan: Make their insurance look valuable.
Price the plan as attractively as possible. Enroll policyholders. Collect their premium dollars … then do whatever they can to keep most of those dollars rather than spend them on healthcare.
For patients, insurance is to help them pay for care. But for insurers it’s a business.
They call paying for care a “medical loss.” And they fight to keep that figure in their favor, to pay less for your care.
Insurance companies advertise robust networks full of physicians and facilities “in-network.”
Then they set up small (or narrow) networks of physicians to save themselves money.
Why? Because if the network is small, odds are more policyholders wind up receiving care from an out-of-network physician.
Meanwhile, the insurers pay just a fraction of the charge to those out-of-network physicians. They know the physicians and hospitals will bill the patient for the balance.
But they don’t tell the policyholder that.
The more enlightened of our patients might ask the doctor, “Do you take x Insurance?”
But x insurance might sell hundreds of plans. Just because we are contracted with some of those plans doesn’t mean we are in-network with all of them.
To lower monthly premiums and make the plans more attractive, insurers also raisedeductibles patients must pay, or limit what is covered.
One plan famously cut all cancer care from a major Texas hospital from its coverage.
Doctors want to be in-network because that sends more patients our way. But getting in can be tough.
The University of Pennsylvania studied Affordable Care Act insurance networks across the country and found Texas among the worst.
They rated 45 percent of the Texas networks as “x-small” and 27 percent as “small.”
One physician told Texas legislators this summer how his practice negotiated in-network contracts with nearly every plan in his area.
But one stubborn outlier company refuses to deal with the doctors. So all of that plan’s policyholders are forced into an out-of-network situation.
Insurers squeeze networks smaller to retain more profits and pay less for care. Frequently, policyholders find out just how narrow their network is during a medical emergency.
Understandably, no patient landing in the emergency room with a broken leg — or worse — will stop to ask whether the doctor rushing to mend or save her is in her network.
And every physician in that ER is focused on easing the patient’s pain and healing her, not on her insurance coverage.
But those physicians are independent contractors at the hospital. They aren’t necessarily in the same networks as the facility itself.
Many of them tried to negotiate to be in-network, to no avail.
Texas Medical Association doctors studied the problem for more than a year, and we prescribe a sure-fire treatment.
We want the state to make sure health plan networks have enough physicians and hospitals.
We want insurance companies to do a better job of explaining to patients the limitations of the plans they buy — before and after the sale.
We want physicians and insurers to tell patients ahead of time who might be involved in their care.
And we want to strengthen the current mediation process patients can use to resolve disputes over surprise bills.
People would not buy auto insurance knowing they could take their car only to one shop to have the insurance to help pay for repairs.
Health insurers are selling insurance to people who expect their insurance is accepted by many doctors and hospitals and will pay for all types of care.
But when they go to use it, they find that is not the case.
We all need to help people understand health insurance and get insurers to be more forthright in their business practices to help their policyholders — our patients.
Don R. Read, M.D., is president of the Texas Medical Association in Austin