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In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.
The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant - 20 to 40 times the usual local rates and (they) often collect the full amount, or a substantial portion.
“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. This contributes to the nation’s $2.8 trillion in annual health costs.
Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies. Multiple state health insurance commissioners have tried to limit patients’ liability, but lobbying by the health care industry stymies their efforts.
“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”
A case in point:
Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.
“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”
In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not.
Dr. Mu’s office did not respond to requests for comment.
The phenomenon can take many forms. In some instances, a patient may be lying on a gurney in the emergency room or in a hospital bed, unaware that all of the people in white coats or scrubs who turn up at the bedside will charge for their services. At times, a fully trained physician is called in when a resident or a nurse, who would not charge, would have sufficed. Services that were once included in the daily hospital rate are now often provided by contractors, and even many emergency rooms are staffed by out-of-network physicians who bill separately.
Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.
In the days after the operation, “a parade of doctors came by saying, ‘How are you,’ and they could be out of network or in network,” Mr. Kaufman said. “And then you get their bills. Who called them? Who are they?”
Doctors’ offices often pursue patients for payment. Ms. Kaufman’s insurer paid about $10,000 to the plastic surgeons, who then sent a bill for the remainder. The couple, of Highland Park, N.J., refused to pay.
When insurers intervene in a particular case, they say they have limited ability to fight back. Insurance examiners “are not in the room on the day of surgery to see the second surgeon walk into the room or why they were needed,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group. And current laws do not require hospitals that join an insurance network to provide in-network doctors, labs or X-rays.
Sometimes insurers just pay — to protect their customers, they say — which encourages the practice. When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the full amount.
Examples:
in network (out of network)
muscle & skin graft $1,781 ($150,500)
spinal fusion $5,893 ($115,625)
gallbladder removal $1,892 ($44,000)
breast lesion removal $688 ($18,500)
The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant - 20 to 40 times the usual local rates and (they) often collect the full amount, or a substantial portion.
“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. This contributes to the nation’s $2.8 trillion in annual health costs.
Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies. Multiple state health insurance commissioners have tried to limit patients’ liability, but lobbying by the health care industry stymies their efforts.
“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”
A case in point:
Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.
“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”
In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not.
Dr. Mu’s office did not respond to requests for comment.
The phenomenon can take many forms. In some instances, a patient may be lying on a gurney in the emergency room or in a hospital bed, unaware that all of the people in white coats or scrubs who turn up at the bedside will charge for their services. At times, a fully trained physician is called in when a resident or a nurse, who would not charge, would have sufficed. Services that were once included in the daily hospital rate are now often provided by contractors, and even many emergency rooms are staffed by out-of-network physicians who bill separately.
Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.
In the days after the operation, “a parade of doctors came by saying, ‘How are you,’ and they could be out of network or in network,” Mr. Kaufman said. “And then you get their bills. Who called them? Who are they?”
Doctors’ offices often pursue patients for payment. Ms. Kaufman’s insurer paid about $10,000 to the plastic surgeons, who then sent a bill for the remainder. The couple, of Highland Park, N.J., refused to pay.
When insurers intervene in a particular case, they say they have limited ability to fight back. Insurance examiners “are not in the room on the day of surgery to see the second surgeon walk into the room or why they were needed,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group. And current laws do not require hospitals that join an insurance network to provide in-network doctors, labs or X-rays.
Sometimes insurers just pay — to protect their customers, they say — which encourages the practice. When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the full amount.
Examples:
in network (out of network)
muscle & skin graft $1,781 ($150,500)
spinal fusion $5,893 ($115,625)
gallbladder removal $1,892 ($44,000)
breast lesion removal $688 ($18,500)
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