How 'Balance Billing' Can Blindside Patients With Unexpected Medical Debt

Feb 3, 2018

A lot of people assume that if a hospital is in their insurance network, the doctors who treat them there will be, too. But that’s not always the case — and it can leave patients on the hook for thousands of dollars in unexpected charges. 

NHPR’s Casey McDermott took a look at how this is playing out in New Hampshire, and what lawmakers are trying to do to address it.

One morning back in August, Donna Beckman woke up feeling dizzy and just not quite herself. After a trip to Seabrook Emergency Room, it turned out everything was fine.

“The physician ultimately came in and said to just follow up with my primary care doctor, which I did the following day,” Beckman says. “They just did a medication adjustment, and off I went. And I've been fine since.”

Fine, that is, until she got the tab for the visit. Soon after she got home from the hospital, Beckman received an invoice for the visit addressed from Owascoag Emergency Physicians LLC and informing her that she owed $1,648 for the “emergency evaluation and management” she received at Seabrook ER.

Related story: Company Known for Surprise E.R. Bills Expands in N.H.'s Healthcare Market

A review of Beckman’s medical records shows that she was charged the most expensive rate for emergency care — meant for the most severe patients.

“[The doctor] was probably behind the scenes ordering the tests, et cetera,” Beckman says. “But the face-to-face time was less than 5 minutes. ‘Follow up with your primary care. Bye.’ That was that.”

After going around and around on the phone with the hospital and her insurance company, Beckman found out that Seabrook ER — and its parent company, Portsmouth Regional Hospital — outsources some of its medical staff to other companies like Owascoag Emergency Physicians LLC

And even though Portsmouth Regional Hospital and Seabrook Emergency Room are in Beckman’s insurance network, the Owascoag doctor they sent her was not. 

“It's very difficult, because it just came out of nowhere,” Beckman says. “A person would have a reasonable expectation that you go in, ‘Oh yes, here's your insurance,’ they take the insurance — and then they just send in some random caregiver who is out of network.”

To make matters more complicated, Owascoag Emergency Physicians is also affiliated with EmCare — a company that has come under scrutiny for inflating emergency room charges in hospitals across the country.

Portsmouth Regional Hospital did not respond to questions about its relationship with Owascoag and EmCare, or its billing practices at large. In a statement, a spokeswoman said only that the hospital "is sensitive to bills that patients may receive from affiliated or contracted physicians, and we encourage those physicians to participate in the same insurance networks as we do.”

The charges Beckman is grappling with are standard operating procedure in health facilities all across the country, sometimes leaving patients on the hook for $100,000 or more

Donna Beckman says a trip to Seabrook Emergency Room in August left her with a surprise doctor's bill of more than $1,600.
Credit Casey McDermott, NHPR

But patients like Beckman often have no way of knowing about these charges until after they’ve gone home and received a bill from the doctor who wasn’t covered by their insurance. In health policy circles, the practice is known as “balance billing.” 

“It’s sort of one of the most absurd things,” says Loren Adler, who studies health policy at The Brookings Institution. “Because no reasonable human being would think to check — well, not that it’s even possible to check — that every doctor involved in your care in the case of an emergency, or really in any case, is actually going to be in your insurance network.”

Adler’s written extensively on the issue of balance billing and what might be done to curb it. While it can happen across all kinds of specialties, he says the emergency care market is especially susceptible.

“This is unlike any good you buy in a normal setting,” Adler says of emergency medical treatment. “You know, if they charged you $1,000 for a cup of coffee, you would say no and even if you accidentally had to pay it once, you would certainly never go to that coffee shop again and tell your friends to never go to that coffee shop.”

Now, just imagine if there was only one coffee shop in town, but you really needed a cup of coffee to stay healthy, and you need it now — but you don’t get to see how much it costs until after you drink it. That’s kind of how the emergency care economy works.

“No matter what they charge, it has basically no influence on the volume of care they will receive,” Adler explains.

But more states, including New Hampshire, are trying to find a way to even the playing field for patients.

Hopkinton Rep. Dave Luneau is sponsoring a bipartisan bill that tries to make sure patients aren’t stuck with these surprise charges. The goal, he says, is to simplify things for the patient.

“When a patient walks through the front door, whether it’s a hospital or a clinic, to see a doctor that’s in the patient’s network, all the other wraparound services associated with that healthcare service — whether it’s anesthesiology, pathology, radiology — would also be covered, as the patient would expect that to be covered, because the patient’s plan actually says all these things are covered," he explains.

Instead of leaving it to patients to deal with leftover costs, the bill tells insurance companies and health providers they have to work out the charges themselves. If the two sides can’t agree, they can ask the New Hampshire Insurance Department to weigh in. The agency wouldn’t determine a specific price, but it would have the authority to decide whether the amount being proposed is “reasonable.”

The insurance department is on board with that plan. Tyler Brannen, a policy analyst with the agency, says they rarely endorse legislation but felt it was important to step up on this issue.

“We feel this is a real consumer concern,” Brannen says. “And we feel the answer, the solution, the bill they’ve come up with is one of the best compromises out there.”

Luneau has tried to tackle ban balance billing several times before, but his earlier efforts ran into skepticism from fellow lawmakers and industry lobbyists. He’s optimistic this year’s proposal will be more successful: It has the support of Gov. Chris Sununu and a bipartisan group of lawmakers, and it’s the product of a months-long study committee that convened to get input on the issue last fall.

Still, not everyone’s a fan of the proposed reforms. Lobbyists for local hospitals and physicians groups have argued the changes would limit their flexibility and make it harder to fill staffing gaps, especially in more rural areas. Opponents also point to a lack of hard data about how frequently it happens in New Hampshire.

But Josh Kattef, a Concord resident who successfully fought back on his own balance bill a few years ago, says that’s because the system is so hard to navigate that most people just throw their hands up.

“There’s this like this giant murky triangle of like everybody pushing the consumer around with the consumer’s complaints, and 90 percent of the consumers just give up,” says Kattef, who sat on the study committee that came up with this year’s balance billing proposal.

Brannen, with the insurance department, also said it is tricky to pin down data on the scale of the problem.

“Most of the time, the patient won’t know to come to the insurance department to resolve these situations. And indeed, they may be able to resolve it working directly with their insurance company,” Brannen says. “That being said, we’ve talked to a number of people who said, ‘Oh yeah. That happened to me. I just paid the bill.’

Donna Beckman says she might have been inclined to do just that — if the bill wasn’t so expensive.

“It just seems to be an unreasonable amount of money for the service that was provided,” Beckman says. “If it hadn't been such a large amount, I may have just written the check — painfully written the check and sent it on the way — just thinking that's the cost of having emergency healthcare.”

In the meantime, Beckman says her insurance company has offered some help. They sent her a check and told her to forward the payment along to Owascoag Emergency Physicians, along with an explanation of her insurance benefits.

But that was in November. As of this week, she says the check still hasn’t cleared.

Update: After this story was published, a representative from Envision Healthcare, the parent company of the physicians group that billed Beckman, told NHPR they "take [their] patient billing very seriously" and worked to address the issue with Beckman's E.R. bill once they "were alerted to her concerns." Envision said they will accept $218.98 ($186.14 from the insurance company plus $32.84 in coinsurance, the same payment arrangement she tried to complete after speaking with her insurance company in November) as payment in full, instead of the $1,648 they initially charged. While Beckman still hasn't received any confirmation that her earlier payment has been processed, she plans to void that check and send her payment online instead. "Hopefully," she said Tuesday, it will be "the last small irritant to fix this mess."