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ACA complaints at one year
Old 10-01-2014, 02:57 PM   #1
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ACA complaints at one year

NY public radio talk show had a short segment and got some callers complaining about the high deductibles, which results in higher costs for people earning enough not to get too much subsidies but don't get employer-provided coverage:

The Brian Lehrer Show: Obamacare's First Birthday - WNYC

I know high deductible plans seem to be better received here, because it reduces premiums while mostly providing protection against catastrophic events which could drain retirement savings.

The other part of it is that a lot of providers are opting out or wanting to opt out as insurers reduce reimbursement rates. Not clear if this was happening before the ACA but some are alleging that the insurers are using the "cover of Obamacare" to really slam providers.

OTOH, there are stories of some providers gaming the system by billing for services with very minimum or little consent ahead of time by patients.

For instance, a hospital in network insists on assistant surgeons who are out of network and end up billing patients much higher fees than the primary surgeon/doctor with whom the patient had been planning the procedure:

http://www.nytimes.com/2014/09/21/us/dr ... -well&_r=1

Then there are cases of specialists whose services are tacked onto emergency care at hospitals which are in network but again, allow a lot of "independent contractors" who've opted out of insurers networks, often because they couldn't agree on reimbursement rates. So they get to charge whatever rates they want and patients who receive care at emergency room are often not in a position to consent:

http://www.nytimes.com/2014/09/29/us/co ... ealth&_r=1
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Old 10-01-2014, 04:00 PM   #2
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Originally Posted by explanade View Post
For instance, a hospital in network insists on assistant surgeons who are out of network and end up billing patients much higher fees than the primary surgeon/doctor with whom the patient had been planning the procedure:

http://www.nytimes.com/2014/09/21/us/dr ... -well&_r=1
I have a friend that had a brain tumor removed. She went through all the pre-approval process with her insurance company and the medical facility before the surgery (she had researched the surgeon she wanted and traveled across the US to have him do the surgery). She got a $10K bill from another surgeon who was in the OR assisting her primary surgeon. The assisting surgeon was not in-network. She had no idea there was even going to be an assisting surgeon and had no idea who was in the OR during surgery, outside of her primary surgeon.

Just another example of how difficult it is for any one patient to control costs in our system.

Every year I keep thinking that it just isn't possible for American families to absorb more increases in their health care costs. And yet every year costs continue to go up at rates greater than inflation or annual income.

I wonder where the breaking point is.
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Old 10-01-2014, 04:02 PM   #3
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They could have done this before ACA as well so I don't see ACA as a good scapegoat.
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Old 10-01-2014, 04:08 PM   #4
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I have a friend that had a brain tumor removed. She went through all the pre-approval process with her insurance company and the medical facility before the surgery (she had researched the surgeon she wanted and traveled across the US to have him do the surgery). She got a $10K bill from another surgeon who was in the OR assisting her primary surgeon. The assisting surgeon was not in-network. She had no idea there was even going to be an assisting surgeon and had no idea who was in the OR during surgery, outside of her primary surgeon.

Just another example of how difficult it is for any one patient to control costs in our system.....
If I were her I would offer to pay whatever she would have had to pay if the assisting OR was in-network and not a penny more. I would favor regulation that if you go to an in-network hospital and your doc is in-network that the facility can only bill of in-network unless you are informed and sign off on out-of-network charges. That would nip these jerks in the bud.

There is no way a consumer can sort this out ahead of time - the facility has to do it and pay the consequences if they screw it up.
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Old 10-01-2014, 04:29 PM   #5
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They could have done this before ACA as well so I don't see ACA as a good scapegoat.
May be true but there's some suggestion that the ACA has caused insurers offering plans on the exchanges to really push reimbursement rates down, causing more doctors to opt out of networks.

I would think though that these kind of billing practices didn't just spring up in the past year. Plus, I'm sure there are consultants advising doctors on how and when to set themselves up as independent contractors and making themselves available at in-network hospitals and facilities.

Twenty years ago, I had knee surgery and the bill for the surgery plus a 2 or 3 day stay at a hospital came up to around $20k IIRC. Some of the items being billed were really crazy, like hundreds of dollars for crutches.

I don't recall having to pay anything under my employer coverage but the itemized bill from the hospital was sobering.
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Old 10-01-2014, 06:51 PM   #6
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I think it's actually a little different - more plans are offered and have not signed up that many doctors yet, or doctors are pushing back because of the admin load of yet more insurers. They still belong to the main, blue cross, united health, etc, just not the newest ones. I live in Mass where we have had a version of ACA for a long time - but a bunch of new "insurers" are in the market (since ACA) and when you look for doctors, they don't have many. Most of these are in the low end pricing wise. I am not sure if this will change or these low cost insurers will end up like a private medicaid. If people pick the lowest cost plan, they will be in for a lot of pain.

Medicaid has very low reimbursement rates, and many doctors do not accept it. This has always been an issue.
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Old 10-01-2014, 06:59 PM   #7
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I have a friend that had a brain tumor removed. She went through all the pre-approval process with her insurance company and the medical facility before the surgery (she had researched the surgeon she wanted and traveled across the US to have him do the surgery). She got a $10K bill from another surgeon who was in the OR assisting her primary surgeon. The assisting surgeon was not in-network. She had no idea there was even going to be an assisting surgeon and had no idea who was in the OR during surgery, outside of her primary surgeon.
Only $10K? She got away lightly, compared to this guy...
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Old 10-01-2014, 08:40 PM   #8
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Originally Posted by Live Free View Post
I have a friend that had a brain tumor removed. She went through all the pre-approval process with her insurance company and the medical facility before the surgery (she had researched the surgeon she wanted and traveled across the US to have him do the surgery). She got a $10K bill from another surgeon who was in the OR assisting her primary surgeon. The assisting surgeon was not in-network. She had no idea there was even going to be an assisting surgeon and had no idea who was in the OR during surgery, outside of her primary surgeon.

Just another example of how difficult it is for any one patient to control costs in our system.

Every year I keep thinking that it just isn't possible for American families to absorb more increases in their health care costs. And yet every year costs continue to go up at rates greater than inflation or annual income.

I wonder where the breaking point is.
Did she consent to have an "assisting surgeon"? Was the need for 2nd surgeon due to a surprising new finding or an emergency situation? Was the procedure so complex that it routinely would require a 2nd surgeon? If not, I would think she would be justified in telling the 2nd surgeon to buzz off and dispute/refuse the bill. Or threaten to sue the second surgeon for assault, since (apparently) that she had not consented to have him/her touch her or even be in the OR during her surgery.
That said, for most procedures I've had the pre-op consent says something to the effect that I was consenting to have 'whateversurgery' performed by or under the direction of 'Dr. X'. IIUC, to ensure that Dr X actually does the surgery you must modify that consent clause to state specifically that you consent to have ONLY Dr X perform the procedure unless there is an emergency or specific unforeseen circumstances. If I were traveling cross-country for surgery I would make damn sure this issue was crystal clear before I even left home.
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Old 10-01-2014, 08:49 PM   #9
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I believe one of the NYT articles linked above talks about certain hospitals insisting on the second surgeon, over the objections of the primary surgeon.

Sounds like these independent contractors will not go away with the bills, whether or not the insurance pays. That means they'll pursue the patients.
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Old 10-01-2014, 09:33 PM   #10
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Look at the bright side, if this were pre-ACA she would have still been billed for the assisting surgeon. This stuff was going on well before the ACA.

But then, were this pre-ACA and if she was on her own insurance (not thru an employer), her insurance provider would most likely have cancelled her policy, because there was nothing prohibiting the insurance co from doing so, and she was clearly costing them money.

And then, she would have truly been up sh!t creek because no other insurance carrier would touch her.

Just sayin.
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Old 10-01-2014, 09:33 PM   #11
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In California, my understanding is that balance billing an insured patient for emergency room care by an out-of-network physician is illegal.

Kaiser has a chart listing the various state approaches. State Restriction Against Providers Balance Billing Managed Care Enrollees | The Henry J. Kaiser Family Foundation
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Old 10-01-2014, 09:39 PM   #12
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The NY Times reporter who wrote the articles appeared on a talk show. She noted that NY state is also instituting a law next year which will make it illegal to bill over in-network rates in emergency rooms.

May cause premiums to go up.
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Old 10-01-2014, 09:48 PM   #13
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We had to pay out of network costs for a surgery last year. Out of network charges at in network hospitals have been a big issue in U.S. health care well before the the affordable care act became law. In our case it wasn't an emergency but how do you shop around for medical services you don't even know you need and then they are performed in the hospital OR while you are unconscious? The whole process is a scam to consumers.

We got the insurance to pay a bit more and then negotiated to pay around half the balance. If the bill had been higher I would have hired a claims specialist to try to negotiate a lower payment.
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Old 10-01-2014, 09:56 PM   #14
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So after reading through most of this thread, I fail to see how the majority of these concerns are related to the ACA and not just health care insurance issues that were previously and would have been ongoing problems in our system regardless of implementation of the ACA.


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Old 10-01-2014, 10:05 PM   #15
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There seems to be a suggestion that the ACA causes insurers on the exchanges to push down reimbursement rates, causing more providers to be out of network, leading to alternate ways for providers to boost their incomes.

The insurer that I had with employer coverage also offers plans in the CA exchange. But their provider networks are different. The PCP I used to have under Anthem Blue Cross is not in the network of the BC ACA plans in the CA exchange.
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Old 10-01-2014, 10:18 PM   #16
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There is one political party trying to repeal the ACA so there are lots of suggestions about the shortcomings. Have you read anything with hard numbers about the out of network problem bigger than it was, other than being bigger because now millions more people have health insurance?
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Old 10-02-2014, 06:30 AM   #17
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So after reading through most of this thread, I fail to see how the majority of these concerns are related to the ACA and not just health care insurance issues that were previously and would have been ongoing problems in our system regardless of implementation of the ACA. ....
+1 unless one has an axe to grind....
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Old 10-02-2014, 06:36 AM   #18
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I agree with others that the practices cited are flaws in the US system not new to the ACA. As pb4uski notes, this could be nipped in the bud with regulations in a heartbeat. All we need is a Congress that wants to improve the system rather than makes points with their bases for elections.
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Old 10-02-2014, 06:49 AM   #19
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There are certainly some unintended negative consequences of the ACA, but I think some providers and others are using it as cover -- as an excuse -- to do what they wanted to do anyway but now have some "justification" for doing so.

And the usual talking heads will spin it out of control and remove any discussion on how to make it better and turn it into an ideological crusade one way or the other. Kind of a shame, really. And until we have a Congress that is willing to work to fix the aspects that both parties agree need fixing, rather than trying to simply preserve or repeal the status quo to appease their respective party bases, it will continue.

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As pb4uski notes, this could be nipped in the bud with regulations in a heartbeat. All we need is a Congress that wants to improve the system rather than makes points with their bases for elections.
In other words, this.
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Old 10-02-2014, 06:55 AM   #20
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I bet "we" (the members of this forum) could come to a consensus on some improvements that would have a positive impact right quick. If only Congress and the President would agree to make us king for a day!!
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