The big honkin’ loophole in the ACA

I’ve noticed this — I’ve been getting all kinds of charges for things I was never charged for before! Gee, if only we had politicians that could actually fix this:

Leo Boudreau of Massachusetts was thrilled to find a psychologist in his insurance network to treat his teenage daughter for emotional stress related to a medical condition. The therapist worked out of a local hospital.

But he was surprised when the bill for each visit contained two charges: the approximately $100 he expected to see for the therapist — and a similar fee for the room, which was not covered.

“How could it be that the doctor was in network and the hospital was in network, but I had to pay separately for the room?” Mr. Boudreau said.

As insurers ratchet down payments to physicians and hospitals, these providers are pushing back with a host of new charges: Ophthalmologists are increasingly levying separate “refraction fees” to assess vision acuity. Orthopedic clinics impose fees to put an arm in a cast or provide a splint, in addition to the usual bill for the office visit. On maternity wards, new mothers pay for a lactation consultant. An emergency room charges an “activation fee” in addition to its facility charges. Psychologists who have agreed to an insurer’s negotiated rate for neuropsychological testing bill patients an additional $2,000 for an “administration charge.”

In some cases, such as refraction, the services were never typically covered by health insurance but had generally been performed gratis as part of an exam. In others, the fees are novel constructs. In any case, as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.

Some of the charges come directly out of patients’ wallets at the time of treatment and catch patients off guard. And if they do not write a check for the refraction fee, for example, many doctors will not dispense a prescription for the glasses.

When Laura Gottsman took her 15-year-old daughter to the Palo Alto Medical Foundation in California last month with a broken arm, she had to sign a special form agreeing to pay for the sling if the insurer did not. A sling charge? Both of her daughters previously had broken arms set at the clinic, and she had not encountered such forms or charges.

“There really wasn’t an option to say, ‘No, I don’t want the sling,’ ” she said. She had not yet received the bill. Liz Madison, a spokeswoman for Sutter Health, which owns the clinic, said that a sling counted as a type of durable medical equipment and that patients typically paid for such items.

Cindy Weston of the American Medical Billing Association, an industry group, said it was up to physicians to decide what to include in their principal payment and what merited an extra charge. She said they now “may be forced to charge” for new services because the Affordable Care Act “has shifted so much responsibility for payment from insurers to patients” and patients do not pay as reliably as insurers.

2 thoughts on “The big honkin’ loophole in the ACA

  1. 99% of all physicians have nothing at all to do with what gets billed, how it is billed or who gets the bill. The physicians billing department and the insurance companies make those decisions. That was Weston’s first big lie. Her second big lie concerns the ACA “shifting responsibility for payment from insurers to patients.” That never happens. And as long as insurance companies are running the show, which they currently do, it will never happen. Medicare for all. Medicare is a universal single payer system regulated by the federal government. Insurance companies have nothing to do with Medicare except when a participant hires one of them to expand the coverage that they already get from the government. For example under Medicare the individual pays 20% of the cost of a hospital stay. If they don’t want to pay that 20% they buy and pay for added coverage. We need to junk the entire for-profit heath insurance industry and join the rest of the civilized world in a single-payer system. Medicare for all.

  2. Yes, Imhotep, those physicians do have a big say in it, since they are normally the ones who own the partnership or corporation that they run their practices thru.
    I had Kaiser in San Diego for over a year, back when they were good, and I really liked them, and they made getting check ups and that kind of shit so easy to schedule and painless in the wallet. The rest of my life has been uninsured up to age 34, and only medical emergencies for the rest, even though I supposedly have good insurance (Blue Cross). It is such a hassle to make an appointment, or find a new doctor, or get a referral when you need something besides a GP. Then you waste a day off an a copay to see a GP to get that referral, and you have to sit thru that fucking GP trying to get you on as many medications as they can because they’ve got some sort of legalized kickback grift going on (like statins and other cholesterol medicines, even though you’re young and your cholesterol is borderline high, but you ratios are fantastic). So far I’ve had a mole removed that ended up costing me out of pocket as much or more than if I’d been uninsured, and a hernia repair surgery. I stepped on a rusty nail that went kind of deep into the arch of my foot, once when I was in a new town; and gave up on the insurance company finding me a place I could go to for a simple disinfectant and maybe a tetanus shot. After 4 hours of rage filled frustration, I decided to take my chances with tentanus. When I complained later, they told me I coulda/shoulda gone to an emergency room. Like I was going to risk bankruptcy for a little iodine swabbing and a bandaid.
    I say fuck the greedy ghoulish doctors, they are just as responsible if not more responsible for our rip off artist medical system as anyone else.

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