In the Oct. 12 “Bill Tracker: Preventing 'surprise balance billing' in health care,” you described a situation where a patient is hit with a surprise bill, even though they were seen at an “in-network” facility. I believe there is a lack of understanding as to why this happens. Many insurance companies do not contract with hospital specialists as a way to defer costs to the patient.
The problem of these out-of-network charges is rooted in insurance industry business practices. It comes when the patient needs to use hospital services and goes to an institution that they think is in-network. To the patient’s surprise, they get stuck with a large bill they were not expecting. In essence the patient is taking on risk that they think they are getting rid of by buying insurance.
State lawmakers have proposed a plan to address this issue. Unfortunately, the plan benefits insurance companies and not the patients I serve and care for. Pathologists are strong advocates for requiring insurers to maintain health insurance plan network adequacy for hospital-based physicians. Specifically, we advocate that insurance regulators require health insurance plans to have sufficient numbers of in-network physician specialists (pathology, radiology, emergency medicine, and anesthesiology) at in-network hospitals.
The insurance industry opposes our advocacy efforts in this area. The failure to have adequate insurance networks of hospital-based physicians means that even when patients purchase insurance products, their services could come from out-of-network physicians at in-network facilities. These narrow and ultra-narrow networks created by health insurance companies shift costs to patients and the physician community strongly opposes this action.
The legislation pending in Harrisburg does not address the problem; it ignores the state oversight of the insurance industry and their coverage obligation to patients.
Pathologist at UPMC Pinnacle