No more surprises, please.

A doctor discusses the problem of surprise billing for ER patients.

Seems like a fair position to allow billing by out of network doctors, but keeping within a reasonable amount.

Unfortunately, it may not be the equitable solution. I would suggest that ER patients need to be shielded from surprise bills by the very definition of the type of treatment. It is emergency treatment, after all. A patient often has little choice in the matter and may not even be conscious. Most health insurance plans I know of have a blanket fee for ER and they don’t specify where that service can take place. Any ER should do.

So doctors that work on call for ER should expect to abide by the compensation schedule the insurance companies have with the ER’s.

Next is the surprise bill for elective treatments that might bring in other physicians during surgery for whatever reason. They should accept the billing arrangement with the patient’s lead physician’s plan or not treat. Some of those “surprises” happen when the patient is under anesthesia and is tantamount to a form of extortion, in my opinion.

Of course, this mess is a result of the myriad of insurance companies and plans that put patient care not about the choice of physician, but rather the health plan. And face it, who knows what services might be needed when signing up for health insurance, so picking networks and specialists is almost pointless.


18 thoughts on “No more surprises, please.

    1. I agree that is the goal. I am concerned, however, that the Warren/Sanders approach is a deal killer for many voters. Certainly for the unions that have premium insurance benefits in their contracts.

      (I think that is part of our problem also. I believe whatever system we have, people need to have some skin in the game commensurate with their ability to pay. Going to the doc for a sniffle because its no cost is silly for most working Americans.)

      I think Buttigieg and Klobuchar have a good point when they discuss a public option. Americans have to see if the government can handle an insurance program for the non-Seniors on a buy in system.

      I know and you know that the cost of a payroll deduction for Medicare for All would be much less than the $20K++ for a private family of four coverage. And that is probably true for just about anyone under $200K pay scale. But Warren has shot that tax hike in the foot with her “no tax hike for the middle class”. That is not on solid ground.

      But a few years on a public option hooked to Medicare and it won’t be hard to convince many Americans that their median income neighbors are paying $5000/year for insurance while they are paying 4 times that. And their employer determines what kind of coverage they get.

      Meanwhile, I really believe the Democrats need to keep the “eyes on the prize”, and that means Congress and the Presidency. Even if it means toning down the Warren/Sanders rhetoric.


      Liked by 1 person

      1. The issue with the public option is if you let rich people opt out of public goods, the quality rapidly deteriorates. Schools, infrastructure, transit are all good examples of this principle. If the wealthy have to slum it with the rest of us, that ensures services will be to a higher standard (their standard).

        As of this morning, Sanders and Warren are polling at a combined 37% compared to Buttigieg and Klobuchar at a combined 10% (Politico), so I’m not sure “toning down the Warren/Sanders rhetoric” is the way to go.

        Liked by 1 person

          1. Actually, the polling in 2016 was accurate, particularly if you visited 538, which carefully aggregates multiple polls that are also rated for accuracy and methodology. As we approached the election Nate Silver of 538 did predict a very close race that could go either way.

            In the end, it was the prediction, not the polls, that erred. Most good polls were well within the margin of error.

            The tiny edge in three states swung the winner take all votes for the electoral win. The popular vote was spot on.

            Liked by 1 person

      2. You keep throwing this $20k number around like everyone pays it. The average full out of pockets costs for employees on employer plans for a family of 4 in 2019 were just over $6k a year according to the Kaiser Family Foundation. That would be a vast majority of the population. The true costs of Medicare for all keeps going up and now estimated at over $38 trillion over 10 years but we all know that number is far too low, always is in government estimates. My biggest beef is why is there such a huge difference between what is billed and what the insurance agreed amount is. Why can’t the “agreed amount” be the standard for everyone? In that we will probably find mutual ground.


        1. Here is the chart from Kaiser:


          The national average is just under $20K. Just because the employer pays 2/3 of the total amount does not lessen the cost of the insurance. Plus that also means the employee costs the employer the salary and another $14K on top of that. Add in the copays and deductibles and the 3% payroll deduction for Medicare (half paid by employer and half paid by employee) and it becomes a serious amount of income going to one sector of the economy.

          I agree the ridiculous differences charged to the uninsured, who already probably can’t afford premiums, is a travesty.

          Liked by 1 person

    2. I don’t think M4A will do any of that, but it will consolidate billing and records, and eliminate a huge % of State dominion and profit motive in the money-changing, resulting in an immediate one-time 10-20% cost reduction. There are still many issues to resolve on pharma, and service costs, but it also forces providers into a weaker negotiating position — they can’t just refuse to deal with, say, Aetna, plus the FBI is the primary investigator of fraud.

      As for unions and Cadillac plans, they can still have that with the supplement insurance plan, i.e., Plan F.

      Liked by 2 people

  1. Agreed.

    I still remember when my daughter was born. We knew in advance it would be a C-section, worked everything out with the hospital and physician’s group, etc. Thought we had it all paid up.

    Lo and behold, here comes a $1,500 bill from the anesthesiologist. $1,000 for being out of network, $500 for the anesthesia itself, because the charge was more than what was usual and customary. Wife got some damn good drugs I guess!

    Of course, there’s not a damn thing we could have done about either of those charges. No way to comparison shop, no way to know that, in an in-network hospital with an in-network doctor, you can find yourself with an out-of-network anesthetist. What was I going to do, say no, just let my wife bite down on a mouthpiece, I’ll hold her hand and you just cut her open and take the baby out, no drugs.

    And Nancy is exactly right – the gross waste in the system from all these plans, all these companies, etc. with their own thing is huge. To say nothing of the monopolistic practices of health care providers. LOL, I see Sentara out with a new wellness initiative:$100-million-community-investment.aspx Sentara is putting up $50M of the $$.

    Tell me, where did that money come from? Must be nice to be able to overcharge people to have $50M lying around.

    Liked by 3 people

    1. My secretary’s son broke a bone when he was 10 playing football. While in the hospital, a doctor stopped by his room, picked up his chart, asked “How are you feeling?”, walked out and billed $1200 out-of-network.

      She threw a fit. The insurance company claimed there was nothing they could do, but eventually they got the hospital to eat the cost.

      Apparently, ambulance-chasers are not restricted to the legal profession, but at least they DO work for it.

      Liked by 3 people

  2. Surprise medical bills are a direct consequence of using insurance to pay for health care. They arise because in the collection of contracts that surround health care delivery there is no contract that specifically defines the rights and protects the interests of the patient receiving care.

    The doctors and nurses have contracts with the hospital, the hospital has contracts with the insurance company, but as a practical matter, the patient has no contract with anyone involved in his care.

    The patient has a contract with the insurance company, you might say, but that contract is non-specific. By “non-specific” I mean two things:

    • First, the insurance contract with the patient is not for services, but for financing. The contracts for services exist between the doctor and the hospital and between the hospital and the insurance company.
    • Second, in the insurance contract with the patient, the patient is legally defined as the seller, not the buyer. As the seller, the patient has no right or remedy with respect to how the buyer uses the thing sold. He has a right to expect the buyer to honor the contract, but no right to say how the buyer does so.

    In whole, then, the insurance model creates a situation where the patient has no enforceable contract to protect his interests with respect to specific health care he may need or receive.

    This makes perfect sense when you think about it. The whole point of the insurance model is for patients to receive services they can’t or don’t pay for. But when you don’t pay for something, then you’re not entitled to have any control over what you get.

    The only solution for preventing surprise medical bills is to eliminate insurance as a mechanism for paying for health care. This applies to social insurance, such as M4A, as well. Under the current system, surprise medical bills affect individual patients privately, one at a time. Under a socialized system, medical bill surprises will be, well, socialized, meaning they will affect all of us, all the time.

    Why? Because, as now, there will be no contracts/controls to prevent them.


  3. I am not sure how the patient is the seller. What is he selling?

    He is buying insurance and with deductibles and copays he is buying direct services and products out of pocket from the providers.

    Insurance contracts are very specific as to what procedures and products they will fully or partially pay for and what your responsibility is right down to exact percentages. Yes, you could call that a financing arrangement. But it is also a price list through a “buying club” in which you are guaranteed certain prices expressed as copays or percentages.

    The issue is the “network”. With M4A, all providers are in-network.

    I was shopping for a procedure a year ago and I had to pass on one highly recommended specialist because he did not take my insurance. That’s stupid. It means I have to guess what my needs are years later and hope my preferred provider is in-network.

    Also the contract your insurance company has is with the doctor and, separately, the hospital. Now it may be that a company like Sentara has both. That is a ploy by large healthcare organizations like Sentara. By bringing in doctors’ groups, they monopolize the field so the upper hand in negotiations is no longer the insurance companies with their offer of millions of patients in return for a good price. Now if insurance companies want certain top notch specialty groups, they have go to Sentara hat in hand.

    Eliminating insurance is fine if you can afford to pay out of pocket. Even the most judicious saver in the median income range or higher would have a tough job accumulating amounts to cover serious injuries and major diseases. That means carrying at least catastrophic coverage with a HSA.

    As far as no control if you don’t pay for services, that is not true. You are paying your insurance company to be your representative in negotiations with the providers. They can get a better deal than you.

    Liked by 1 person

    1. RE: “I am not sure how the patient is the seller. What is he selling?”

      The patient sells his money (premium) to the insurance company in return for indemnification (the policy). That, at least, is how a lawyer explained it to me once when I thought I had a claim against an insurance company because my policy didn’t cover something I thought it should.

      The technical term for the insurance company in the context of the contract is contingent debtor. That is, the insurance company has an obligation to pay when the agreed-upon contingency materializes. Hence the insurance company is the payer (buyer) for purposes of the contract. The insured, or patient, is the creditor who takes the promise of payment in consideration for selling his money.

      The consequence of these legal arrangements is that the patient never formally buys the medical services he receives under a health insurance policy. The patient isn’t even a party to any of the contracts by which the services themselves are provided.

      Again, the whole point of health insurance is that the insured receives benefits he doesn’t pay for. To make that possible requires a constellation of contractual relationships, none of which the patient is a direct party to.

      It’s not a workable system.


      1. I can’t debate the convolutions of the legal interpretations.

        However, I disagree with this part:

        “ …the insured receives benefits he doesn’t pay for.”

        The premiums are an advance payment that is pooled with many others for the benefit of the few who do run up big medical bills. It is just like most any other insurance such as car, home, flood, term life, disability.

        Not to mention that you do pay out of pocket for copays and deductibles before the benefits accrue.

        If you don’t pay the premiums, you don’t get any benefits.

        Liked by 1 person

      2. RE: “However, I disagree with this part…”

        Study the difference between these two statements:

        a) The insured receives benefits he doesn’t pay for.

        b) The insured doesn’t pay for any of the benefits he receives.

        Then go back and read the history of Blue Cross/Blue Shield, which we covered here in the Forum. Notice that none of the insureds in the original BC/BS pays enough in premiums to cover the whole cost of a hospital bill. The system only works because some of the insured pay premiums but never incur a hospital bill.

        RE: “The premiums are an advance payment that is pooled with many others for the benefit of the few who do run up big medical bills.”

        Nope. As explained, the premiums are a loan to the insurance company that doesn’t even have to be repaid unless some pre-defined event occurs.


        1. Well, I will be more than happy to “lend” my insurance company some money each month provided it covers my $250,000 unforeseen medical bills.

          If I don’t need it, I’m happy, and if I do need it, I’m relieved. Like buying a fire extinguisher.



        2. RE: “Well, I will be more than happy to ‘lend’ my insurance company some money each month provided it covers my $250,000 unforeseen medical bills.”

          Well, if you, personally, are the issue and not surprise medical bills, where they come from and why, then I have nothing to add.


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