They picked Miami Valley. It was in-network, near their home in Oakwood, and the family had been there before.
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But even though the hospital was in-network — the term used to describe agreements for reduced rates negotiated between providers and insurance companies — the plastic surgeon who operated on Reid Rupp was not. Five weeks later, the Rupps received a medical bill for more than $17,000.
It’s common for hospitals to contract with doctors who are not on staff, and patients aren’t always told they will be billed separately by the doctor. If the doctor and insurance network don’t have an in-network agreement to keep costs down, patients can get stuck fighting a high bill they thought would be covered by their insurance plan.
Hospitals and doctors say it’s difficult to pre-emptively explain what the total patient cost will be, particularly in emergencies. Out-of-network physician groups have also argued that the reimbursement rates they get from insurance companies aren’t adequate for them to join a network plan, leaving them little choice but to pass their costs onto their customers.
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Surprise bills more common
Surprise billing — the term used in the industry — has become more common as hospitals contract out for more services. About 65 percent of U.S. hospitals contract out their ER staffing and management, according to 2014 data from Merritt Hawkins, a physician staffing company.
A 2016 study in the New England Journal of Medicine of more than 2 million claims from one large insurer found 22 percent of its ER billings involved an out-of-network provider. And in almost every case, the patient had gone to an in-network hospital.
Congress and legislatures in different states have attempted to tackle the problem, but there is no legal protection against surprise billing in Ohio.
Lisa Rupp, a Beavercreek City Schools teacher whose insurance covers her college-age son, said the family is now fighting the $17,000 bill they received for his treatment.
Rupp said it was an emergency situation, but that Reid was stable by the time a plastic surgeon was called. She said she and her husband would have searched for a different doctor if they knew the size of the bill they were facing.
“We were not afforded that choice,” she said.
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‘It’s not by accident’
The plastic surgeon who operated on Reid Rupp, Dr. Kenneth Christman of Miamisburg, charged about $19,000 — $2,000 of which was picked by the family’s employer-funded insurance plan. The family hasn’t paid any of the balance, appealing to anyone they thought might be able to help: their insurance company, benefits broker, Christman’s office, Miami Valley Hospital, their state representative and the Ohio Attorney General’s office.
Christman’s debt collection agency, Doctors Credit Service, said in an Oct. 17, 2017, letter to the Rupps’ attorney that the doctor would like to discuss his out-of-network fees with the patients and their families “but all the hospitals that he has worked out of have blocked/prohibited him from doing this.”
Premier Health, which owns Miami Valley Hospital, clarified its position in its response to the newspaper. Under federal law physicians are not supposed to discuss finances with patients until they have been screened and stabilized, but Premier stated its written agreements with out-of-network doctors require that patients be informed of their billing status once they are stable, Premier says. The agreements also require that these physicians work with patients after the fact to reasonably resolve billing issues, according to the hospital network.
Lisa Rupp said the bill from Christman’s office caught the family off-guard.
“We’re not prepared to pay that kind of money,” she said.
Rupp’s attorney, Adam Sadlowski, argued that surprise bills like this one amount to fraudulent concealment.
“It’s one thing if it’s discussed from the outset and it’s disclosed before the procedure occurs so they can make an informed decision as consumers, as patients,” he said. “But it’s not and it’s not by accident.”
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‘We don’t wait around’
Christman said he couldn’t specifically discuss Rupp’s case because of patient confidentiality. But in emergency situations, he said, “we don’t wait around to see if their insurance company is willing to allow them to have life-saving care or not.”
“We encourage patients to look at their insurance to see what it covers and doesn’t cover and we can’t predict what one is going to do verses another,” he added.
Christman’s practice does not contract with insurance companies for in-network rates but accepts payments from insurance companies if they decide to pay, Christman said.
“What some (insurers) are doing is they are paying very, very little,” he said. “Sometimes they will pay less than Medicare or even Medicaid on some things, and doctors can’t keep their doors open with those kinds of payments.”
He charged that insurance companies are making big profits while squeezing small practices like his that don’t have the negotiating power to get a contract with a fair reimbursement level.
“We try to charge a reasonable amount and we try to be fair with patients and with insurance companies,” he said. “We’re not seeing the reciprocity there we would hope to see.”
Insurers argue that it’s the providers making profits at the expense of patients.
UnitedHealthcare, the largest insurance company in the U.S., took steps in 2015 to curb how much it will pay when patients with its polices are surprised in emergencies with bills from out-of-network physicians working at hospitals. UHC argued at the time that it was “deeply concerned that some hospital-based physicians are establishing out-of-network strategies to seek excessively high reimbursement levels.”
America’s Health Insurance Plans, which represents the health insurance industry, said consumers would be better protected if doctors accepted the same insurance as the hospitals where they practice.
“This would go a long way to reduce and prevent consumers from receiving a big surprise balance bill,” the advocacy group said.
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Premier Health wouldn’t comment on the specifics of the Rupp situation, citing patient confidentiality, but said in a statement that it has little control over the billing that occurs between an out-of-network physician and a patient beyond the written agreements it has with the doctors.
“There is no law in the state of Ohio that requires independent physicians to contract with health insurance companies,” Premier’s statement says. “While we work closely with our independent physicians on coverage issues, the choice to enter such contracts ultimately rests with them. Please know that it is not always possible for us to know the status of these contracts at any given point in time, especially in trauma/emergency cases, when immediate care is paramount for the health of the patient.”
‘The choice is yours’
The bills have kept coming for the Rupp family. After Reid’s initial surgery on the night of his accident, he later needed follow-up care to remove the arch bars from the original surgery that had his mouth temporarily wired shut. Lisa Rupp said she tried unsuccessfully to find another doctor where her son could go, but she ended up sending him back to the physician who did her first surgery: Christman.
The follow-up procedure led to an additional $1,500 out-of-network bill, she said.
She also said the family had a $10,000 out-of-pocket bill for the dental work Reid needed as a result of the accident.
Christman’s office and his debt collector have continued to try to bill the Rupps. A June 21, 2017, letter from Christman’s accounts receivable department to Reid’s father Christopher says: “Please be advised that there are two ways of settling this debt — timely payments or protracted and unpleasant collection effort. At this time the choice is still yours. Please send payment today.”
Ohio law stalled
An effort by Ohio lawmakers to build more transparency into the billing process led to a legal challenge that is ongoing.
Rep. Jim Butler, R-Oakwood, sponsored a bill that was passed by the legislature in 2015 that required an estimate in “good faith” of what a medical bill would be in non-emergency cases.
But the Ohio Hospital Association and other medical professional groups filed suit, saying the law would be unworkable, and a court granted an injunction to stop it. Gov. John Kasich’s administration also has yet to write rules creating the guidance that would allow the law to take effect.
“It’s been extremely difficult to fight against the most powerful special interest lobby in Columbus that really doesn’t want patients to know what the prices are,” said Butler, who filed a motion to intervene in the suit against the law he authored.
Butler said one way to rein in rising health care costs is to give consumers the medical pricing information they need to seek out cheaper care.
“The missing link is we don’t know what the costs are so we can’t shop around,” he said.
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John Palmer, spokesman for the Ohio Hospital Association, said hospitals recognize it’s a challenge for consumers to understand medical costs and are taking steps to help patients.
The association recommends that hospitals have advocates on staff to assist patients with understanding their billing.
Hospitals are not opposed to transparency, he said, but he argued that Butler’s bill would actually harm patients by delaying their care while information is tracked down from insurance companies.
In a follow-up statement, the Ohio Hospital Association said: “The health care market has changed dramatically and patients rightfully are asking for more information about the cost of their health care. Hospitals want to empower patients to fully understand cost obligations and, aside from any law or regulation, are providing more information to patients.”
Sen. Sherrod Brown, D-Ohio, also introduced a bill in Congress in February to curb the practice of surprise billing, though his bill was for emergency care. S.B. 284, which has yet to receive a hearing, would require two written notices to insured individuals letting them know whether a provider or hospital is in-network and estimating any potential out-of-network fees.
“Too many Ohioans are surprised by out-of-control medical bills after undergoing a procedure they thought was covered by their insurance or after being rushed to an out-of-network emergency room,” Brown stated. “Having spent their hard-earned money on health insurance to prevent surprise medical costs, Ohio patients shouldn’t be punished for lacking the time or the information to make the best medical decision.”
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Find an advocate
Scott McGohan, CEO of McGohan Brabender, an employee benefits broker, said his firm battles these types of claims once or twice month.
“The big issue is somebody wants to blame somebody,” he said. “It’s either an insurance company issue or a health system issue and quite frankly, they are probably equally to blame in the problem.”
McGohan urged patients to find an advocate to help them navigate complex billing issues and seek solutions. They could try to negotiate the bill down, meet with the health system about financial assistance programs or payment plans, appeal to their insurance company, talk to their insurance benefits broker about options, access tools to prevent the bill from impacting their credit, or seek help from the Ohio Department of Insurance.
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Expecting families to check ahead of time that the radiologist and the anesthesiologist and the whole surgery team is covered by their insurance company is a lot to ask, McGohan said.
“It would be very clunky and very difficult to teach a consumer to ask all those questions when one of their family members is in one of those situations,” he said.
Newspaper asks questions; woman’s bill is forgiven
Questions asked by the Dayton Daily News in a billing dispute involving a five-year-old Urbana boy with epilepsy led to a $500 savings for the boy’s mother.
Lindsey Evans’ son requires multiple hospitalizations per year that are covered through Children with Medical Handicaps, a supplemental insurance program offered through the state of Ohio.
In November, Evans received a surprise bill for $500 stemming from her son’s October 2016 visit to Mercy Health’s Urbana Hospital.
Unknown to her, the treatment her son received during that visit was provided by US Acute Care Solutions, a physician group that contracts with the hospital to provide ER services. The group sent her an out-of-network bill.
Evans was exasperated.
“Am I supposed to ask ‘excuse me what employer are you with?’ when my son is rushed into the ER for an uncontrollable seizure?,” she said. “I’m sure I’m not the only one with this experience. Many children with (Children with Medical Handicaps) are in rural areas and have no other choice but the closest hospital.”
Evans, feeling she had exhausted all other alternatives, entered into a payment plan. But when this newspaper contacted Mercy Health last week, a spokeswoman said Evans’ costs were due to a billing error. Evans was told later that day that her bill has been fully written off.
“US Acute Care Solutions never puts patients enrolled in a government program like this in the position of having less coverage than if it was in-network,” said Nanette Bentley, a Mercy Health spokeswoman who said she was relaying information from the physician group. “The surprise bill she received was issued in error and US Acute Care Solutions is working directly with the patient’s mother to correct the error.”
Evans was surprised at the new development, saying she had been told the supplemental coverage would not be accepted.