Survey Finds High Fees Common in Medical Care

Survey Finds High Fees Common in Medical Care

Published: August 11, 2009

A patient in Illinois was charged $12,712 for cataract surgery. Medicare pays $675 for the same procedure. In California, a patient was charged $20,120 for a knee operation that Medicare pays $584 for. And a New Jersey patient was charged $72,000 for a spinal fusion procedure that Medicare covers for $1,629.

Maxine Hicks for The New York Times

Ryan Davis and his mother, Maria, at their Miller Place home. The family was billed $6,000 for three stitches he received under his lower lip at the local hospital's emergency room.

The charges came out of a survey sponsored by America’s Health Insurance Plans in which insurers were asked for some of the highest bills submitted to them in 2008.

The group, which represents 1,300 health insurance companies, said it had no data on the frequency of such high fees, saying that to its knowledge no one had studied that. But it said it did the survey in part to defend against efforts by the Obama administration to portray certain industry practices as a major part of the nation’s health care problems.

The health insurers, saying they felt unfairly vilified, gave the report to The New York Times before posting it online on Tuesday, explaining that they wanted to show that doctors’ fees are part of the health care problem.

The group said it had used Medicare payments for comparison because Medicare was so familiar and payments are, on average, about 80 percent of what private insurers pay.

“It’s the wild, wild West when it comes to prices of anything in the U.S. health care system, whether for a doctor visit or for hospital charges,” said Jonathan S. Skinner, a health economist at Dartmouth.

The situation is so irrational, said Uwe E. Reinhardt, a health economist at Princeton, that it simply cannot go on. “We will not emerge out of this decade with this lunacy,” Dr. Reinhardt said, adding, “You worry about credit card charges, you scream for consumer protection — why not scream for it here?”

But Dr. Robert M. Wah, a spokesman for the American Medical Association, said there was another side to the story: insurers’ low payments to doctors who enter into contracts with them and the doctors’ difficulties, in many cases, in getting paid at all. That is why, he said, doctors may simply abandon insurance plans. Then patients end up with extra fees because they have to go outside their networks.

Karen M. Ignagni, president and chief executive of America’s Health Insurance Plans, had a different view, saying: “As we think about the health care debate, what’s been talked about is, What are the cost-sharing levels? What are the premium levels? How much do health plans pay? No politician has asked how much is being charged.”

Some of the health care legislation being considered by Congress would require insurers to increase their disclosure to patients of possible out-of-network costs. And President Obama has proposed changing how Medicare sets its payments to doctors and hospitals. But there are no specific proposals to control prices for out-of-network medical services.

In the survey, patients were insured but saw doctors who were out of their networks of care providers. Those doctors have no obligation to accept the out-of-network fee from insurers as payment in full. Patients may then be accountable for the balance.

“That is what generally happens,” said Susan Pisano, a spokeswoman for the health insurers’ group. “The consumer is responsible.”

The survey looked at 10 companies that insure patients in the 30 most populous states; the companies provided some of the highest bills from 2008. Researchers excluded two types of charges that were likely to be erroneous: those that were greater than 10,000 percent of Medicare’s fees for a procedure, or more than 2,000 percent of Medicare’s fees and also more than 50 percent higher than the next-highest bill for the same procedure.

State laws protecting patients from getting stuck with medical bills in excess of their normal deductibles or co-payments vary widely, said Betsy M. Pelovitz, the group’s vice president for state policy. And, she said, the laws often offer little or no protection to patients who seek care outside their insurance networks.

In New York, patients with managed-care insurers cannot be asked to pay more than the applicable co-payment, deductible or co-insurance for an ambulance regardless of whether the provider is in or out of their network. In New Jersey, hospital emergency rooms treating Medicaid managed-care patients must accept Medicaid payments as payment in full and cannot bill patients extra. In Connecticut, a state law says it is “unfair trade practice” for medical providers to ask patients to pay more than a deductible or co-payment for services covered by their insurance.

But in general, patients hit with high bills from out-of-network doctors and hospitals may have little recourse, said Leslie Moran, senior vice president of the New York Health Plan Association. “When patients dig in their heels and say, ‘No, I’m not going to pay it,’ it sometimes goes to collection,” she said.

While there is no way of knowing how often doctors submit exorbitant bills, insurers tell America’s Health Insurance Plans that they see such bills “all the time, every day,” Ms. Pisano said.

The New York Health Plan Association provided more examples. In testimony at a state hearing in October, it told of a Long Island surgeon who charged $23,500 for an emergency appendectomy. The patient’s insurer paid its out-of-network fee of $4,629. The surgeon demanded the balance or said he would force the patient to pay. The insurance company paid the bill.