(Photo: Michael Nagle/BB)
A flood of surprise hospital bills could start arriving in U.S. mailboxes as early as January unless two giant for-profit health care companies resolve a dispute over whether thousands of doctors remain in patients' insurance networks.
America's biggest health insurer, UnitedHealth Group Inc., is pitted against one of the country's largest employers of doctors, Envision Healthcare, in a massive contract fight over prices that Envision's 25,000 emergency doctors, anesthesiologists and other hospital-based clinicians charge.
A contract impasse would mean that UnitedHealthcare's 27 million privately insured patients could face expensive, unexpected doctor bills as of Jan. 1 when Envision doctors would become out-of-network.
Envision has already been criticized for its billing practices in situations where its doctors don't participate in patients' health plans. A Florida man got a bill for $2,255 from an Envision subsidiary after being treated by an out-of-network emergency doctor in 2014 for a facial injury, according to a lawsuit he filed earlier this year.
In another case, a California woman went to an in-network hospital for abdominal pain and found she needed emergency gallbladder surgery. The operation was covered, but she faced $4,447 in bills from Envision for two trips to the emergency department.
A judge dismissed the Florida case, and the case in California is in settlement talks.
"With emergency-room docs, patients don't have any control, don't have any ability to stay in a network," said Paul Ginsburg, a health economist and director of the USC-Brookings Schaeffer Initiative for Health Policy.
The standoff comes as patients and policy makers are increasingly fed up with unexpected medical bills and soaring insurance expenses that can sink a family's finances. More than half of Americans have gotten an unexpected medical bill, according to an August survey by the research group NORC at the University of Chicago. About 1 in 5 emergency-room admissions resulted in a surprise out-of-network bill, economists from the Federal Trade Commission reported in 2017.
"With emergency room docs, patients don't have any control, don't have any ability to stay in a network."
Insurers contract with networks of doctors and hospitals to negotiate how much they will pay for their members' medical care. In many health plans, patients can still see doctors outside of that network, and the insurer will often pay some portion of the bill. But out-of-network providers are free to try to collect the rest of their charges from patients directly. That practice, known as balance billing, has enraged consumers and drawn scrutiny from regulators.
Several states including California, Florida, and New York tried to restrict the practice. Both Republicans and Democrats have sponsored federal legislation this year to limit charges for patients when hospital doctors are out of network.
Big money is at stake. Envision gets about $1 billion in annual revenue from UnitedHealthcare, the company says. Its total revenue last year was $7.8 billion. UnitedHealthcare said about 650,000 of its members received care from Envision clinicians last year.
Both companies have been trading blame for the hit patients will take if they don't reach a deal over the terms of reimbursement, though both sides remain hopeful about reaching agreement. While stand-offs between insurers and medical providers are common, the stakes are especially high in this one because of the size of both companies and the fact that patients have little ability to avoid Envision's doctors in emergency situations.
The conflict has been heating up since October when UnitedHealthcare published a letter it sent to hospitals warning that an impasse could leave their patients dissatisfied "from higher out of pocket costs and patient confusion." It also set up a website accusing Envision of "price gouging" with charges double the average for emergency services.
