Costs, Health Literacy, Insurance, Needs Navigation, Trust
Advancing Person-Centered Care Will Address the Issue of Surprise Medical Bills
Melissa Williams shares a solution to addressing surprise medical bills that will work for patients.
By Melissa Williams
In the spring of last year, I suffered a missed miscarriage that required an acute surgical procedure with general anesthesia. Given my familiarity with surprise medical bills, I knew to be proactive and ask if the facility and doctors attending to my care would be in-network with my insurance plan. When the scheduler called me the day before my procedure, she confirmed that the facility and surgeon were both in-network, but she could not tell me whether the anesthesiologist would also be in-network. She indicated that I would have time to speak with the anesthesiologist before the procedure and that he or she can answer any of my questions then.
When I arrived at the hospital on the day of my surgery, I asked the intake specialist if she knew if the anesthesiologist would be in-network. She made several phone calls to attempt to find the answer, but was not able to get a hold of anyone. Pressed for time, she ultimately told me to ask the pre-op nurses who would be preparing me for my surgery. “They should know,” she said.
As the pre-op nurses were preparing my IV and drawing blood, I asked them if they knew whether the anesthesiologist was in-network with Anthem, my insurance plan. They exchanged glances. “You know,” one nurse said, “I don’t know. We’ve never been asked that question before. I’ll see if I can find out.” She left the room and after ten minutes or so, she returned and said the same thing the scheduler had told me the day before, “The anesthesiologist will be here before your procedure. You can ask her then.” She also added, “You can also contact the hospital’s billing department should you have any problems once you receive your bill.”
A half hour or so before my procedure, I finally met the anesthesiologist and asked if she knew whether her group was in-network with Anthem. “I believe so,” she responded, “I have Anthem too and never received an exorbitant bill after I had a procedure here with anesthesia. You should be fine.”
Thankfully she was right. I was fine and I never did receive a surprise medical bill, but that whole experience left me asking so many questions:
- Why was it that the anesthesiologist could only tell me that I was in-network from her own personal experience?
- How has “no one ever asked” if the anesthesiologist is in-network prior to a procedure taking place?
- Why didn’t anyone talk to me about costs?
- Why could no one tell me whether my anesthesiologist was in-network yet pharmacy staff are able to tell patients right away whether a particular medication is covered by their insurance plan?
- In the future, should I write on the consent form: “I will not be financially responsible for any out-of-network care that I haven’t consented to first.”?
Although I received amazing clinical care from the nurses, doctors and hospital staff, the fact I had to ask multiple people whether the anesthesiologist was in-network was incredibly frustrating. While I was nervous about my procedure (and devastated over the miscarriage), I was more nervous about potentially being balance billed. I couldn’t help but think that this whole experience should be better for patients. It should be person-centered.
Over the past year, there have been countless news stories about surprise medical bills. Both Vox and Kaiser Health News / NPR have done an excellent job spotlighting the pervasiveness of balance billing practices as well as highlighting how medical debt impacts everyday lives. The issue has gotten so much attention that both Congress and the President have recently vowed to put an end to surprise out-of-network bills. Many states have also taken it upon themselves to address this issue. Currently in Virginia, there is a bill (SB 1763) before the General Assembly that would prohibit balance billing in emergency settings and also protect patients from being seen by out-of-network providers in non-emergency situations unless they’ve consented to the care.
On both a personal level and through my work at National Patient Advocate Foundation, I’ve been following the issue of balance billing for years, so it’s encouraging that it is finally getting the national attention that it deserves. Medical debt continues to be the second largest issue affecting patients seeking assistance from Patient Advocate Foundation case managers. In a study conducted by West Health and NORC, 54% of Americans received a medical bill for a cost they thought was covered by their health insurance, and 53% received a medical bill saying that the amount owed was higher than expected. To be frank, it’s about time that we see policymakers and health care stakeholders come together to address a serious issue impacting hundreds of patients.
As policy proposals continue to be drafted and considered, I think it’s important for patients and patient advocates to come together to advocate for person-centered solutions to address balance billing. If person-centered care principles were better integrated throughout our health system, I think less people would encounter surprise medical bills. If insurers, hospitals and physicians adopted person-centered care principles:
- Insurers would have tools for patients so that they can easily determine if a certain provider is in-network or out-of-network;
- Prior to a planned procedure, patients would be notified whether the providers are in-network or out-of-network as well as expected out-of-pocket costs in addition to their cost-sharing requirements. Patients would have the opportunity to ask questions, explore other options and consent to the services.
- Patients and hospital staff / physicians would have conversations about costs. The exchange would be meaningful—with physicians and patients using shared decision-making to determine the best course of action based on individual circumstances.
- Patients would be assessed for financial risk with referrals to appropriate safety net services.
- All health care information would be transparent, understandable and accessible to patients.
I imagine that my own experience would have been very different if any of the above bullets had taken place. I likely would’ve been equipped with enough information to feel confident not only about the procedure, but knowing that I wouldn’t receive an unexpected medical bill. Taking care of our health should not be a gamble. Until our health care system embraces conversations about costs and inviting input from patients, we as patients must continue to ask questions about costs and network status. Perhaps if all patients begin asking whether a particular provider is in-network, then physicians, insurers and hospital staff will have no choice but to be equipped with answers.