Have you ever accidentally wound up seeing an out-of-network doc only to learn you’re on the hook for the bill? You’re not alone! A 2015 Consumer Reports survey indicated nearly 33% of patients got medical bills they did not expect.

According to an August 2016 article in STAT news, patients get hit with extra charges because even if their main doctor is in network, other medical professionals working on their case may not be. This can happen when an in-network surgeon is paired up with an out-of-network anesthesiologist in surgery.

This leaves patients holding the bag for potentially thousands of dollars in expenses they did not anticipate or budget for because they thought they were insured. See this CBS report on a Glendale, California woman who ended up being billed $27,000 in out of network charges even when she consulted an in-network doctor!

As Slate.com reported on August 11, 2016 in their series United States of Debt (only free to view for the first two weeks. Otherwise, you have to subscribe), having health insurance will not protect you from medical bankruptcy. In fact, medical bills are the #1 cause of bankruptcy in our country. Slate shares the true stories of three insured families to illustrate different facets of the problem, including out-of-pocket costs, out-of-network doctors, and forgoing care because of its cost.

So one would think that with a problem this widespread and harmful, everyone would be in agreement about how to solve it. One would be wrong!

While currently there is a bill – AB 72 (Bonta)– in the California Legislature that seeks to take patients out of the hot seat, many doctors are opposed to it. Why? Let’s take a closer look at the bill to understand their objections:

AB 72 says, “Hey, Dr. Out-of-Network, the patient’s insurance company will pay you 125% of the Medicare rate for your services. Your patient will only be liable for what they would have paid for an in-network doctor. And if you don’t like it, Doctor, you can arbitrate with the health insurance company. You may not ‘balance bill’ your patient.”

Some doctors believe this is equivalent to “capping payments” and they don’t like it. They think the correct solution is to make the health insurance companies expand their provider networks.

Specifically, these doctors believe AB 72 should be amended to include the following wording:

“health-care (sic) plans should be required to maintain full provider lists covering all specialties. The plans should provide these lists to their in-network providers and to all of their subscribers and customers.  Networks that fail in this requirement should be penalized by fines and disciplinary action against their managers and officers.”

What does HEAL California think? Well, even though the doctors are really fighting for the freedom to charge whatever they want, which is screwed up too, we think they do have a point. Provider networks are very problematic and solutions like AB 72, while helpful, don’t go far enough.

To be clear, AB 72 will help protect patients and their families from unexpected “balance billing” and for that reason, we support it. But as a solution it unfairly singles out doctors. We believe there are plenty of other “bad players” in this mess.

For example, what about the “disconnect” between health insurance companies, hospitals and doctors? None of these people seem to be talking to each other! Hospitals can hardly feign ignorance about how health insurance works, because we all know how thoroughly Admissions reviews our insurance coverage before admitting us!

So we believe hospitals should make every effort to financially protect their insured patients by assigning in-network providers at every opportunity or documenting that it was not possible to do so. This should not be especially hard to do (except for unidentified emergency patients) because they have all our insurance information in their files. AB 72 doesn’t address this.

And what about the health insurance companies? AB 72 directly benefits them! Because it means they don’t have to pay what the doctor normally charges for care. They only have to pay 125% of what Medicare would pay. And yet it was the health insurers who created the problem in the first place with their terribly inadequate networks.

So, why aren’t provider networks regulated? Good question. In California, we have regulations on the books about networks, but enforcement is nonexistent per Consumer Watchdog in a November 2015 press release. This is outrageous! Health insurers should not be let off the hook anymore! Again, AB 72 doesn’t address this.

Bottom line, we believe there should be one provider network available to everyone and every doctor should belong to it. If you live in San Bernardino and your kid needs to see a genetics specialist at Sloan-Kettering in New York City, your insurance should cover that specialist. If your mom, living in Downey, has a complex back injury and the most experienced surgeon with cases like hers is at UCSF, your insurance should cover that surgery. No “ifs, ands or buts.”

But, until we are free of provider network hassles, here’s what you can do:

Get informed! Check out this highly informative Surprise Bills Advocates Guide with an overview of the problem and different state solutions.

Learn more about HEAL California’s solution, Improved Expanded Medicare for All, and remember, a healthcare system where your needs come first is within reach!

And join us to make it a reality! Like us on Facebook and follow us on Twitter!

Together we will win!