ActivePaper Archive DIAGNOSIS: COSTLY&CONFUSING - Philadelphia Inquirer - Philly Edition, 11/15/2015



Medical bills keep soaring, and so does out-of-pocket spending. With no easy solutions in sight, the best a consumer can do is learn — and fight.


Julie Cios of Bucks County says going over medical bills is her “part-time job.”


Julie Cios with her paper trail of medical bills and insurance documents. She has contested high costs and won many battles, but she says the work is exhausting. BRADLEY C BOWER / Staff Photographer

The Cios family of Bucks County could be a living advertisement for the wonders of modern medicine: dad’s double knee replacement, mom’s successful treatment for thyroid cancer, their two teenage daughters’ repairs of assorted sports injuries.

Along with the benefits, however, comes a flip side: a never-ending array of billing and insurance complications that are growing increasingly familiar to Americans wrestling with the health-care system.

There were the out-of-network radiologists who read X-rays at a cost of $75 to $95 for each of four, vision and hearing screenings that were supposed to be 100 percent covered as preventive services ($68 for each child), physical therapy ($369) that should have been free because the deductible was paid, not to mention the higher deductible itself, which rose to $4,000 last year.

Julie Cios, 54, says she wins most of her fights with doctors, billing agencies, and the company that provides insurance through her husband’s employer, but it takes a toll.

“It is my part-time job,” Cios said right after a trip to the billing office at Lansdale Hospital to haggle over a $60 charge for a mammogram that was, unbeknownst to her, read by an out-of-network provider in June. Oh, and then there was a $15 late fee tacked onto a bill she knew nothing about.

The plethora of calls Cios must make to reduce even a single payment reflects something most everyone involved in the health-care system can agree on: The problem is big, complicated, and there is no easy fix.

Accurately listing network status for all providers would help. So would requiring providers and insurers to figure out disputes rather than putting patients in the middle.

But with so many players involved, and so many problems, even making logical changes can be like trying to repair a car while it’s speeding down a rutted road.

For now, the best way consumers can protect themselves is to take a page from Cios: Know your options, piece by piece, and exploit them fully.

No one ever lost out by challenging a medical bill. But there was far less need to until recently. Health insurance used to mean a modest premium deducted from a paycheck, a manageable deductible, and perhaps a small office visit co-pay. After that, everything was covered.

Now, it is alot more expensive. And mystifying. This is open-enrollment season for many Americans covered through their employers, Medicare, or the Affordable Care Act marketplace. Studies suggest most people stick with the same plan, largely because shopping for a new one is so daunting. It can pay to shop around, experts say.

But even consumers who spend hours scrutinizing their coverage can encounter costly confusion, and what Cios would call nonsense.

Nearly a third of Americans with private insurance were surprised by a bill for which their insurer paid less than expected in the last two years, according to a Consumer Reports National Research Center survey. Nearly one-quarter of them had not anticipated a bill from that doctor at all. Many had never heard of the provider.

Perhaps the most perplexing scenario is when you carefully check in advance to make sure that your doctor and your hospital are part of your insurance network but then get a surprise bill in the mail.

This happens even to experts.

Friends Erin Taylor and Layla Parast, who both work in health-care policy at the RAND Corp. in Santa Monica, Calif., thought they had done all the necessary research when they delivered their babies a few weeks apart last year. Then Parast got a $1,600 bill for anesthesia services. Taylor, who moved to California two years ago after receiving her doctorate in health economics from the University of Pennsylvania’s Wharton School, never did.

“Layla happened to deliver on a day when an out-of-network anesthesiologist was on call, while Erin was seen by an in-network anesthesiologist. Purely by chance, one of us received an expensive physician bill and the other did not have to pay a dime,” they wrote two weeks ago on the blog of the journal Health Affairs. Layla eventually was fully reimbursed, but her baby was nine months old by the time it happened.

These sort of out-of-network surprises are most common with anesthesiologists, radiologists, and pathologists. They often involve services that are critical to the outcome of a procedure — interpreting a scan, for instance — but may not take place in the operating room. The hospital might normally use a radiologist on staff; if that person is out, no one is going to ask the replacement if he or she is part of one patient’s network.

Emergency departments, where physicians often are independent contractors, are among the most common source of surprise out-of-network bills, and patients brought in on stretchers obviously can’t do much about it even if they knew. There is one level of protection for emergencies: Insurers must pay the in-network equivalent. But patients may still be on the hook for the difference between the in-network payment and the out-of-network charge.

This is known as “balance billing.”

Nothing else in America works like health care. Imagine, for example, if the medical system sold pizza.

You want a pie. There is no menu and no price. But the guy behind the counter says the $10 in your wallet ought to be enough. You hand over the $10 and your family eats the pizza.

Then you get a $4 bill for mozzarella — the contracted delivery guy had been off that day. And $2 more for gas for the oven, sent by the utility. The guy behind the counter hadn’t mentioned that; he’s never seen a utility bill.

Whose fault is it?

Health-policy experts warn that the fragmented health-care system is not easy to fix; squeeze one side of the balloon and another area will pop out.

Consumers Union, which posts a wealth of guidance on surprise medical bills on its health-topics pages at, cautions policymakers that forcing hospitals and labs to use only members of their networks could lead to service shortages. But requiring insurance companies to pay the full bills submitted by out-of-network providers could result in higher premiums.

“If you’re going to protect the patient, who ends up being responsible?” Larry Levitt, a senior vice president of the Kaiser Family Foundation, asked journalists at a recent health-policy seminar. Legislation has stalled in California, partly because powerful medical groups feared they would be forced to accept lower payments.

Only a few states have passed laws on the issue. Some policy experts are encouraged by New York state’s new law because it is comprehensive and sends billing disputes to independent arbitration.

Legislation being considered in New Jersey is based, in part, on the New York model. Ditto for a bill being circulated by Pennsylvania lawmakers that has not yet been introduced.

The issue of surprise bills from out-of-network providers has been getting more attention lately, prompting Pennsylvania Insurance Commissioner Teresa Miller to hold a hearing — with plenty of surprises presented by consumers — last month.

The consulting firm Avalere Health found that last year’s Obamacare marketplace plans had doctor networks that were one-third smaller, on average, than plans available through employers. In theory, narrower networks would allow insurers to charge lower premiums, which surveys show many consumers want. But subscribers may pay much more out of pocket when going to a doctor or hospital.

And narrow networks aren’t the only reason for surprisingly high bills.

“The main change is that health-care costs keep rising. Some things just seem worse,” said Daniel Polsky, executive director of Penn’s Leonard Davis Institute of Health Economics. He pointed out that Medicare has consistently charged 20 percent coinsurance for hospitalization, but as costs have skyrocketed, so have coinsurance payments.

High-deductible plans, which require consumers to shell out a lot more cash before coverage kicks in, are not evil in themselves, he said. They allow premiums to be lower and fully cover catastrophic medical scenarios. But they used to be purchased mainly by higher-income people who could afford higher costs.

“The change is who has the highest deductibles,” Polsky said. They become a problem “if you don’t have the income to cover the expense or the experience in how to navigate the system.” That describes most of the people buying the federally subsidized coverage.

Particularly egregious, he and others agreed, is when you go to an in-network hospital and get a bill from an out-of-network doctor you didn’t even know was involved with your care.

Virtua Health has been working on that issue, said Bob Segin, executive vice president and chief financial officer. Every one of the 250 or so doctors employed by the nonprofit system must have contracts with the same insurers that the hospitals use, which is nearly every carrier in South Jersey, he said.

Still, that is no guarantee an outside physician won’t be called in as a consultant or to staff the emergency room, and send a bill outside the network. For that, Segin said, Virtua is forming clinically integrated networks — collaborations among its own physicians and independent doctors and other providers — that would both improve care and, in theory, solve the out-of-network issue.

Health systems that own both the treatment and insurance sides of the equation, like highly rated Geisinger in central Pennsylvania, have this built into their design. Virtua hopes to create these networks on its own and take them to the bargaining table when it negotiates new contracts with insurers next year.

In Bucks County, Julie Cios continues getting — and fighting — bill after bill after bill for her 61-year-old salesman-husband, their swimming-and-water-polo-playing daughters, 17 and 19, and herself. “We really utilize our benefits,” Cios said.

She succeeds in most disputes — overcharges that she said should have been covered, preventive care that should have been free, deductibles that were already paid.

And she has learned some tricks.

“The ones that I don’t win I pay $25 a month,” she said, which she said helps avoid referral to collection agencies.

But mixing and matching numbers from physicians, facilities, labs, and “explanation of benefits” statements isn’t how she wants to spend her time.

“We just wish that adoctor’s office would give us a reliable statement at the time of service,” Cios said. “I would rather be told to bring $1,000 or you can’t afford this procedure. End of story.”

215-854-2617 @DonSapatkin

Out-of-network providers can help hospitals with staffing, but it can lead to surprise costs on bills.