Health insurers highlight excessive out-of-network charges

Some California physicians providing out-of-network medical care bill patients at rates far beyond what Medicare allows, a new report from a health insurance trade group shows.

The national survey released Friday by America’s Health Insurance Plans is part of the industry’s effort to show that some medical providers are overcharging consumers and unnecessarily raising healthcare costs. Some critics fault insurers for all too often paying these excessive charges for out-of-network care and then passing along those increased costs in the form of higher premiums for employers and consumers.


In California, the report shows, a pathologist billed $8,100 for a tissue exam in 2011, compared with the Medicare fee of $128.46. Another California doctor billed $30,000 for a gallbladder removal using a laparoscope while the Medicare rate was $778.16, according the industry group.

Medical providers often complain that Medicare rates are too low, and they say they shouldn’t have to accept an insurance company’s deeply discounted rates to become an in-network provider.

The report surveyed the nation’s health insurers in the 30 largest states and asked them to submit some of their highest bills for out-of-network procedures. About 12% of all medical claims were for out-of-network care in 2011, the report found.

Long Beach teacher Lynne Nielsen recently encountered this problem when she had routine knee surgery at an out-of-network surgery center in Costa Mesa. She was featured in a Times report Jan. 31.

Advanced Surgical Partners billed $87,500 as a facility fee for the 20-minute surgery that normally costs about $3,000.

Nielsen’s insurer, Blue Shield of California, initially paid 97% of the bill, or $84,800. Blue Shield sent the check to Nielsen and she refused to sign it over to Advanced Surgical Partners because she felt it was so unreasonable.

Nielsen also asked the California attorney general’s office to investigate the matter.

An attorney for the surgery center later acknowledged the bill was excessive and it agreed this week to accept $15,000 from Blue Shield.

A Blue Shield representative told Nielsen on Thursday that she may now owe the surgery center $2,700 for her part of the arthroscopic knee surgery.

Nielsen said she has no intention of paying the surgery center anything after they billed such an outrageous amount to begin with. The surgery center couldn’t be reached for comment.

“They won’t get any money from me,” Nielsen said. “This just gets more insane.”


Small surgeries, huge markups

Many hospitals, doctors offer cash discounts

Blue Shield’s union ties raise concerns about conflicts

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