Anecdotal: my dad had a heart attack and was in the hospital for 6 months due to complications. After a certain amount of time, the bills started to rack up and we were being charged for services that we thought would be covered under “health insurance coverage.” Instead of being covered, the health insurance provided coverage for standard hospital care, but we were charged every time a non network doctor stepped into his room. Then, the non-covered machines that were used. Then, stupid things like “staying in an ICU longer than allowed by coverage.”<p>My father passed away before making it home, but when all was said and done, insurance was billed $10 million in total, of which the various doctors and hospitals billed the estate $2 million. My dad didn’t have an estate because he had no assets. But imagine your life + childrens’ lives being ruined for having insurance yet filled with invisible asterisks.<p>At the time, NJ laws were onerous in this regard and favored insurance companies so we had no recourse. The state had a process for dealing with issues like this, but it was more of a cursory “jobs done here boss” type process and didn’t provide consumers with relief. Because of that, I moved my family out of NJ. When all contingency plans are filled with asterisks, do you really have insurance/protection?
Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.<p>Let's say you get a hypothetical procedure. Insurance has already agreed to pay in-network providers between $1-3K for this procedure. But you got this procedure out-of-network. Why is insurance's liability suddenly $0 instead of whatever the lowest in-network fee schedule would be ($1K in this example)?<p>See I can understand insurance not wanting to foot substantially higher bills than in-network providers charge, but I cannot understand why it drops to $0 reimbursed when you leave network. It seems like an immoral "gotcha."<p>But then again I'd like to see insurance discounts/agreements banned. Make everything and nothing in-network and also normalize the insured/uninsured prices. No more "$100 for a band-aid, -$99 discount" shenanigans.<p>Obviously single-payer would be better yet still, but if we must keep using this broken private employer-linked insurer system let us at least keep band-aid fixing it until we can get enough political support to scrap it.
I once called 911 when my wife had an Asthma attack that left her unable to speak or stand. She was transfered from an ambulance to a paramedic about half way to the hospital. My insurance covered one as in-network but not the other. My wife was released a few hours later. I was young and it took me about 10 years to pay off the dept I owed. I am extremely hesitant to call an ambulance if the person can be encouraged to move under their own power. So much so, that I was asked to sign papers when a family physician suggested an ambulance. This rule looks like it helps.
This bill misses a big point. IMO should be there is only one price. Insured, in/out of network, regardless. A lot of times the reason an out of network rate is so high is because these providers are charging so much more for the same thing.<p>Additionally it seems we have a supply vs demand issue if healthcare providers have such pricing power. Maybe it's time to open up the training supply and let folks with a 3.3GPA become doctors?<p>EDIT: looks like maybe the supply issue is more about residency than med school <a href="https://www.fiercehealthcare.com/practices/more-medical-students-than-ever-but-more-residency-slots-needed-to-solve-physician" rel="nofollow">https://www.fiercehealthcare.com/practices/more-medical-stud...</a>
I wrote Hacking Healthcare for Orielly, created ClearHealth, yada yada...<p>Devil is always in the details of these rules but on the surface it looks like a good attempt. It is a sort of a bandaid though.<p>To understand why this occurs know that most jurisdictions have certain staffing requirements for service lines. You must have X many neurologists covering X shifts. There is almost universally a shortage of these folks for other reasons, so you end up with a lot of non-staff doctors to fill the coverage requirements. Those non-staff often have different insurance relationships than staff doctors and so are "out of network".<p>The two serious changes that would have a more durable impact on this are to free the lock the AMA has on residencies that exacerbates doctor shortages and to dramatically streamline the way insurance program enrollment is done for doctors. Further opening up interstate health insurance would also probably help.
Hahaha I'm not holding my breath.<p>It's multiple cartels vs us.<p>These cartels have spent literally 2 billion dollars on lobbying politicians.<p>So the real question is, how does this hurt us? How is this helping physicians build mansions, hospitals get record profits, etc...
Wow, on the face this looks like a really great rule. I suspect there's going to be an ton of irate specialists (especially anesthesiologists) who were making fortunes from surprise billing.
We took our son to an emergency room visit 2 1/2 years ago. The hospital was in network and we had insurance. It was a simple case of croup, we were out in a few hours.<p>We just got a bill last month for $300. This was on top of 3 other bills we have already paid over the years for the same visit.<p>The insurance company said they only knew about it a few days before us. So it was a surprise to them too. But by nature of their agreement with the hospital, they were not allowed to fight it.<p>I still wonder how many more bills we can expect.
From the announcement:<p>"Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates."<p>This to me seems to just completely eliminate the difference between in-network and out-of-network billing. What am I missing?
I don't love this solution to the problem.<p>This doesn't help anyone paying cash for services, and it really just invests more into the current broken system.<p>I think the solution is that all healthcare providers must provide upfront pricing for you.<p>Right now, almost all medical billing is surprise billing. It's basically the only sector where this is true.
> Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.<p>This seems like a really big loophole. I was just at the hospital for the birth of my daughter. My wife and I checked in at the OB desk where they asked for acknowledgment that we may be seen physicians that aren't part of the hospital (out of network).<p>We acknowledged, so surprise medical bills are fair game now?
It's straight up not possible to be an informed consumer in the US and avoid this stuff when it comes to health insurance.<p>There's no market of rational decision makers, no choices you can make and really know the outcome when it comes to health insurance.<p>My health insurance is pretty good and yet they randomly send me letters saying that they think the procedure should be covered by some other insurance they THINK I might have.<p>In the meantime they stop covering things and the providers send me bills with no health insurance coverage ....<p>They do this about every 18 months, I think hoping I just pay the bills and not notice.
Seems like a good step. Last year had to have a medical procedure done by an oral surgeon. For some reason there are no in network oral surgeons when it comes to medical insurance. Paid a significant amount up front. Painful but thought that it was all done.<p>Six months later received an itemized bill for another significant amount. The worst part about it is theres no way to know if the bill is correct, or if insurance should of covered one of those line items. They really could just make up whatever they want as the system is so opaque, no one knows how much anything should cost.
I would think you would need legislation to implement this rather than a regulation. The inurance-hospital-doctor lobby is rich and strong. When Colorado was considering a public insurance option, this lobby ran non-stop Fear TV commercials saying this new insurance would kill babies and seniors. (Despite seniors are on Medicare)
If it sticks, this is great! I wonder what law gives them the authority to just make a rule like this, though. I imagine the lawsuits about this issue will go for some years, as we have learned that the whole business model of some healthcare systems in this country is sticking users with these surprise bills.
If congress keeps raising the regulatory burden on insurers without actually addressing the root problem it's just going to cause prices to rise until the bottom falls out.<p>Maybe not bad in the long run but that must be the least efficient possible way to solve this problem.
What I do: Ask the doctor/PA/nurse how much EVERY LITTLE THING they want to do costs before they do it. Sure, it's really annoying and not 100% foolproof, but it has saved me alot of money.
The entire insurance industry should just get axed.<p>USA is dumping twice as much money in as Canada/Europe for worst outcomes.<p>Warren Buffet has described our insurance system as the "tapeworm of the American economy".
Can this be right? “ Two-thirds exit disclaimer icon of all bankruptcies filed in the United States are tied to medical expenses”<p>From someone living in a country (Australia)with proper government medical support, this seems insane!
I find it really hard to believe that US citizens are allowing this abuse and many even defend it. Markets may even be workable if the patient actually had necessary information and hospitals, insurers and multiple middlemen couldn’t design these elaborate bureaucracies that are optimized to confuse people while extracting maximum money.<p>I can’t imagine any other industry getting away with this.<p>I wish the Democrats had had any courage to go for Medicare for all. It’s an established system that could be tweaked to expand coverage. Instead Biden will make some half assed moves which will immediately be obstructed by the republicans.<p>And so this travesty will keep going for many years more.<p>And it seems there is no hope for change.