SAN FRANCISCO (KPIX 5) — When you need surgery or treatment, you check to make sure the hospital and doctor are in your network in order to keep your costs down. But a growing number of Californians are getting clobbered by surprise medical bills from doctors they don’t know and never even met.

Fairfield resident Cassie Ray is one of those Californians. She works for the American Cancer Society and helps patients gain access to care. “I think I’m a pretty savvy consumer,” said Ray.

But even she was surprised and mad when she got a medical bill from a doctor she never even met.

“I was so angry. And I said there needs to be a law to keep this from happening,” exclaimed Ray.

A year ago, she was diagnosed with breast cancer. After a mastectomy, her doctor decided that Ray needed a minor surgery, but this time at an outpatient clinic.

Ray did her homework and confirmed the facility was in network.

Then she got the bill. Everyone was “in network” except for the anesthesiologist.

She called the facility to complain.

“This is in Oakland. It’s a major metropolitan area. It’s not like this was the only anesthesiologist in the area. And they said, ‘Well we never know who’s coming and it’s not our responsibility,'” Ray said.

Ray was now on the hook for unexpected $600.

Her experience is not unique. “It’s unfortunately very common,” said Betsy Imholz of Consumers Union. Imholz is the Special Projects Director for the nonprofit.

According to a recent Consumers Union survey, 30 percent of Americans with private insurance got clobbered with a surprise medical bill  – within the past two years.

Kaiser Family Foundation survey found that 70 percent of those surveyed had no idea the doctor was not in their plan’s network.

And most patients ended up paying the bill that can often run into the thousands of dollars.

Currently, doctors and in network hospitals are not obliged to ensure everyone on the surgical team is in your network. Health plans have a narrower network of doctors who will accept the plan’s reimbursement rates. And a growing number of specialists refuse to take the plan’s reimbursement rates. The cost gap between what consumers will pay in network and out-of-network is growing substantially, and can be prohibitively expensive.

“Everybody points their finger at everybody else in our health care system and the consumer is unfortunately left in the middle,” said Imholz.

Now California lawmakers are considering a bill that offers some relief if you go to an in-network facility and end up getting care from an out-of-network provider.

The bill, known as AB 533, is being carried by Assemblyman Rob Bonta of Alameda. Last year a similar bill failed by 3 votes.

With this bill, if you are faced with an unexpectedly high medical bill at an in network facility, you would now have relief.

“You would not have to pay anything but the in-network cost-sharing, and any amounts you did pay to any provider would count towards your in-network deductible and out-of-pocket maximum,” explained Imholz.

Who would eat the rest of the fee?  Doctors and health plans would have to work it out.

A powerful lobbying group is against it. “Against the bill right now is the California Medical Association. They’re the main opponent,” said Imholz.

The CMA would not agree to an on-camera interview. The group sent KPIX 5 News an email instead, which said:

“CMA always puts patients first and has been working hard to address the incidence of surprise billing in a way that will protect patients and patient access to care. Unfortunately, AB 533 as it is written now isn’t a balanced or workable solution. It provides a windfall to health plans while significantly reducing access to care and participation by physicians, as witnessed in other states, such as New York.

California physicians are seeking a workable consensus on this issue, but not at the expense of access to care. We will continue to work with the author and stakeholders on compromise legislation. Until a solution can be reached, CMA remains opposed.”

KPIX 5 emailed the CMA back, with some follow-up questions as to what was meant by “at the expense of access to care,” but the group never responded.

The concern, as KPIX 5 understands it, is that the bill’s provisions would pay doctors too little and give insurers and health plans too much.

Ray just wants a solution. “Patients should not have to deal with this on top of their illness,” she said.

She fought the medical bill with the help of a health care advocate, but it took her eight months.

In the meantime, the unpaid bill was sent to collections, and ended up on her credit report, which she just recently was able to resolve.

Comments
  1. Geoff Thompson says:

    Allen-

    There is an EASY solution to this. All that is required is for in-network facilities to provide the option on the check-in form to only use in-network personnel. Failure of a provider to do so is to subscribe to the CMA conspiracy to put benefit to physicians above benefit to patients.

    G. Thompson Mountain View

    >