Out-of-network costs spin out of control


https://www.axios.com/billed-and-confused-cindy-beckwith-out-of-network-care-578a22be-b6b4-4959-8333-9e2e970b19d5.html

Out of Network costs vary greatly among California PPO health plans -

People who have health insurance but get sick with rare diseases that require out-of-network care continue to face potentially unlimited costs.

The big picture: Federal regulations cap how much people pay out of pocket for in-network care, but no such limit exists for out-of-network care.

Zoom in: Cindy Beckwith, 57, of Bolton, Connecticut, was diagnosed with pulmonary artery sarcoma, a rare tumor on a main artery. She also has fibromuscular dysplasia, a rare blood vessel condition.

  • She has ConnectiCare health insurance, which she gets through her husband’s employer.
  • Her local doctors suggested she see specialists at the University of Pennsylvania Health System because her conditions were so uncommon, but the system was out-of-network.
  • “I had to go out of my network,” Beckwith said. “I didn’t have a choice.”

The bill: $20,138.40 from Penn Medicine, the parent of UPHS, a profitable system with $8.7 billion of revenue last year.

  • Over a few years, Beckwith received a lot of care from the hospital, including two open-heart surgeries and inpatient chemotherapy.
  • This bill showed charges of $270,000, just for services received in 2019. Beckwith and the hospital settled on $20,138.40. Penn Medicine “insisted” she pay a minimum of $441 per month until 2023, she said.
  • Beckwith and her husband have already paid more than $11,000, and even though she says they are doing OK with her various medical bills, “there’s not a lot of extra money left over.”

Between the lines: The new surprise billing regulation only protects patients if they get non-emergency care from out-of-network doctors at in-network facilities.

  • That means people with employer coverage that doesn’t have an out-of-pocket maximum for out-of-network care could experience large bills based on hospitals’ inflated charges, and have to negotiate payment on their own.
  • “Out-of-network charges kind of seem like a little bit of funny money to consumers,” said Katherine Hempstead, a health insurance expert at the Robert Wood Johnson Foundation. “These are the things that make people feel kind of defeated.”
  • “We didn’t expect this to happen,” said Beckwith, who has worked in medical coding for 30 years, said of her condition. “When it does, it can wipe you out.”

The other side: Beckwith’s hospital and insurance providers did not make anyone available for interviews.

  • A ConnectiCare spokesperson said the insurer does “not speak about our members’ private health information.”
  • A Penn Medicine spokesperson said in a statement the system “has a longstanding commitment to work with patients to help them understand the costs associated with their care, including out-of-pocket costs.”

The resolution: After Axios submitted a HIPAA authorization waiver, signed by Beckwith, to Penn Medicine to discuss Beckwith’s case, Beckwith received a call from Penn Medicine, whom she hadn’t heard from in months.

  • The hospital knocked $4,000 off her remaining balance, telling her they reprocessed some old claims. She still owes almost $4,800.

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