wnyc.org / 93.9fm / am 820

Three main points: (1) An independent “reasonable and customary” database won’t affect consumers covered by “self-insured” health plans (used by large employers/unions). Such plans generally do NOT use “reasonable and customary” to determine out-of-network rates. They have a clause saying that the out-of-network payment rate must be the same as the in-network payment rate, but with a deductible and coinsurance. (2) Cuomo’s win may increase the premiums of “insured” health insurance (where the insurance carrier underwrites the policy) if they have to include outlier charges by non-network physicians. Most individual and small employer plans are “fully insured”. (3) Cuomo would better serve the public by going after the doctors who charge many times more than Medicare rates. If a Medicare rate for a surgical procedure is $2,000 (and private carriers have negotiated an “in-network” rate of $1,800), than a doctor in the Emergency Room (ER) should not be allowed to charge an extortionate rate of $18,000. In the ER, the patient has no choice about what doctor is treating them. (This could be remedied by requiring hospitals to deny admitting privileges to doctors who use extortionate prices.) Also, for non-emergency care, doctors should be required to give provide their prices BEFORE a patient receives services. There are large self-insured groups that can give Cuomo plenty of real life examples of price gouging.

Carol from NJ is correct. When you use a "network" facility (like a hospital) and then you are billed by medical personnel for an amount above the "allowed amount" by the Insurance Carrier -- ALWAYS call the Insurance Company and complain -- as many of these providers (such as radiologists & anesthesiologists) are contractually prohibited from "balance billing". Not always the case, but well worth a try.

Watch out for emergency room visits. The radiology practice at our local (in network) hospital has billed me on two different occasions for the difference between their "customary" charge and what the insurance reimbursed. When I complained to my insurance carrier I was told the charge is a violation of the contract between the insurer and the provider. When I called the provider with that information, the charge was reversed. I can only assume that they do this because people pay without investigating.

To the point: how many health insurers have gone to medical school? By deciding what is or is not covered, they are in essence making medical decisions that affect people's lives. That's what my medical professionals are for.

The Healthcare Insurance industry in the US should be shrunk down to the size where we can drown it in the bathtub.

Get rid of private insurance and let's have universal healthcare.

How about we discuss how the CEO William McGuire of United Healthcare makes $1 billion per year.

maybe we should regulate the pay that the ceo's and other higher ups at the health insurance companies based on 'usual and customary rates'.

I'm shocked, shocked that health insurers are trying to skip out on paying claims fairly!

As a social worker, I often make referrals for treatment for mental illnesses. The rates paid to these providers, both in- and out-of-network, are horrendous. My clients either accept treatment from the least experienced and least qualified therapists, or spend life-altering amounts of money to pay out of pocket. The customary rate for therapy in NY is $150. An out-of-network reimbursement of $30 is both common and unconscionable.

Dr. Scott Shreeve, a healthcare blogger, is trying to get patients to post their EOBs -- Explanation of Benefits -- to the web so that we can all see what the insurance companies are doing.

Transparency Trek: The Million EOB March
http://blog.crossoverhealth.com/2009/01/09/transparency-trek-the-million-eob-march/

Not even United pays double figures, it's a real shame. I've seen payments of $1.43 for a test that was billed at over $20 by the lab!

Just a note about my insurer, Unicare, which has purchased New York Blue Cross/Blue shield as its NYS network. At the beginning of 2007, Unicare reduced out-of-network benefits to Medicare rates, sending members a letter that stated that the change was "mandated." Based on the wording of the letter, our benefits administrator, and presumably others, believed the "mandate" came from the federal government. Of course, that was ridiculous -- the U.S. government doesn't set reimbursement rates. We are lawyers and knew that. Although Unicare originally told my firm that it would not restore our former out-of-network rates, eventually (8 months later), after much negotiation and threats to pull the firm's policy, it did restore those rates. They are still much too low, but better than those that Unicare attempted to foist upon us. Unicare is owned by Wellpoint. Buyer, beware.