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A new survey of out-of-network physician claims finds some extremely high examples of over charging in CT. The highest example includes a bill for $26,881 for a lower back spinal fusion; the Medicare rate for that service is $1,572.95 or 17 times less. The report includes ten examples of out-of-network charges ranging from 1,709% to 648% of Medicare fees. The survey, sponsored by America’s Health Insurance Plans – an industry lobbying organization, asked for outliers; these are not average out-of-network fees. AHIP argues that, as the nation considers health care reforms, the role of provider fees in rising costs must be considered.
All the examples in the survey were for consumers with insurance. According to Vicki Veltri of the Office of Health Care Advocate, CT consumers accessing care out-of-network may be responsible for the difference between the charges and what insurers will pay. For example, if a provider is charging $200 for a service that the insurer believes should only be $100 (the “usual and customary” charge) and the consumer’s policy includes a 30% coinsurance on out-of-network services, the insurer will pay only $70 and the consumer may be responsible for the remaining $130. Of course, there are no rules for uninsured patients. Any consumers facing these costs are urged to call the Office of Health Care Advocate who has been able to reduce or eliminate those bills in some cases. The Office can be reached toll-free in CT at 1-866-HMO-4446. For a tip sheet on negotiating with your provider from the Consumer Health Action Network, click here.
Ellen Andrews