Story of 'Balance Billing,' $1K trip to physician ignites social - NBC12 - WWBT - Richmond, VA News On Your Side

Story of 'Balance Billing,' $1K trip to physician ignites social media storm

Henrico Doctors' Hospital Forest Campus (Source: NBC12) Henrico Doctors' Hospital Forest Campus (Source: NBC12)
GLEN ALLEN, VA (WWBT) -

A Glen Allen woman, fighting a surprise bill after receiving emergency care in the ER, is got results after calling 12 On Your Side. After the story aired, hundreds of viewers reached out to NBC12 to share similar experiences.

Sally Matchett went to an in-network hospital. She says she was blind-sided by a separate bill from the physician who treated her during her emergency room crisis.

It's called Balance Billing, and Matchett wants people to know it's happening before an emergency strikes and catches you completely off guard with a bill you never expected, like it did with her.

Matchett believed her life was on the line during the early morning hours of March 11.

"I was having chest pains, shortness of breath. I really thought I was having a heart attack," said Matchett.

The ER doctor at Henrico Doctors' Hospital Forest Campus administered immediate care and critical tests that showed it was Matchett's gall bladder, not her heart.

Great news...until her statement of benefits from Cigna Insurance arrived, showing coverage denied for the ER doctor.

"It's not fair how it went down. It was almost sneaky. No, I was not notified," said Matchett.

She went to a hospital she knew was in network. Cigna covered previous procedures there, but in this instance, the ER doctor is a member of James River Emergency Group - which doesn't have a contract with Cigna.

Matchett got a bill for $1,180.00. She called 12 for help.

"I felt this was unethical," said Matchett.

12 On Your Side called all three organizations: Henrico Doctors' Hospitals, Cigna and James River Emergency Group. After our inquiry, the lawyer for the doctors' group called Matchett. He offered to settle her bill and reduced it to $191.00, the in-network allowable charge from Cigna.

"If I had not contacted Diane, I don't think this would have gone anywhere. I was hitting brick walls left and right," said Matchett.

She wasn't the only one. After this story aired, hundreds of NBC12 viewers reached out to us with similar trouble.

"I just felt defeated until I saw your program," said Cynthia Hill. "I mean, I was. I couldn't get up and call your number fast enough. I was just shaking, and then when you called me back..."

The Cigna patient says she went to Swift Creek ER on doctor's order after having symptoms of appendicitis. It's an in-network HCA facility, so imagine the shock when Hill got a bill for more than a grand from the doctor, whose assistant treated her in the ER.

James River Emergency Group does not have a contract with Cigna.

"We have insurance. I pay almost $1,600 a month with a $7,000 deductible. I should have been told," said Hill. "There should have been posters everywhere. If you're a Cigna patient, you will get a bill from your ER physician. It is not covered."

Transparency is what people want, who contacted 12 about their surprise ER bill.

"We need to ask Cigna or ask James River physicians, 'what do you want us to do?' I don't want to come and see you because I don't want a $1,200 bill. So, I'm going to sit at home and die."

The firestorm on Facebook ranges from outrage and surprise to confusion.

Laura David posted: "You don't have a choice in doctors - This should be illegal."

John Tatum writes: "We have got to get control of our health care in America and stop this insanity."

James River Emergency Group has not returned calls from Diane Walker, but it did reduce Sally Matchett's surprise bill after we got involved. Now, Cynthia Hill - and many others - are asking for same discount.

"I am. I want help with this. I don't want to pay these people," said Hill.

Cigna released the following statement:

We understand and share Ms. Matchett’s frustration with the surprise bill from the emergency room doctor. When physicians adopt a strategy to remain out of network, they keep the ability to bill the remainder of their charges directly to their patients, known as balance billing, which can cause financial distress to our customers and undermine health care affordability. These impacts are magnified in emergency situations, when patients often lack the opportunity or awareness to protect themselves from this billing practice. Cigna will continue to work with physicians to address this industry-wide problem that puts consumers at financial risk.

We have researched this situation and have found that these claims were processed correctly according to the terms of her specific health plan and deductible as well as applicable law.   

If a Cigna customer is balance billed by a physician, we encourage them to contact the physician’s billing department to negotiate a lower bill and discuss any financial assistance programs that may be available to them.   

Our customer service team available 24x7 to answer questions and can also help connect our customers to programs and resources that can help them manage their health.   

Here is some additional background that we think is important for your story: 

·    Unfortunately, the physician who provided the services in the emergency room does not participate in Cigna's network, even though the hospital does. The hospital -- not Cigna -- determines how it will staff the emergency department.  
·    To date, this physician group has declined to become part of our network, though we are currently in negotiations to reach an agreement on a network contract.  
·    We covered the hospital charges for emergency services at the highest benefit level available under Ms. Matchett’s plan.   
·    We also processed the claim for the out-of-network physician charges under all applicable federal and state rules.  
·    When a health care provider participates in the network, they agree to provide services at a more favorable, in-network cost. They also agree that they will not try to collect from patients any additional amount (the “balance”) over and above what the health plan covered, aside from the individual’s deductible or copayment amounts. 
·    Out-of-network providers do not agree to this same provision. Many will bill the consumer for the difference between what they charged and what the insurance company covered – a practice known as balance billing.   
·    If a Cigna customer is balance billed, we encourage them to contact the physician’s billing department to negotiate a lower bill and discuss any financial assistance programs that may be available to them.   

Statement from Henrico Doctors' Hospital:

Henrico Doctors’ Hospitals is sensitive to bills that patients may receive from affiliated or contracted physicians, and we encourage those physicians to participate in the same insurance networks as we do.

Statement from the Virginia College of Emergency Physicians:

Insurance companies are shifting hundreds of millions of dollars in medical costs to patients each year - costs that used to be covered by health plans. Patients are paying more for less health insurance coverage.

Along with higher deductibles, premiums and cost shares, insurance plans now have increasingly large surprise insurance gaps. These insurance gaps appear when patients go to an in-network facility, and are later hit with surprise out-of-network medical bills for care they thought would be covered by insurance.

These insurance gaps are getting bigger as insurance companies are narrowing their provider networks, paying lower physician reimbursements and therefore limiting choices for patients and often, access to necessary specialists.  

At the same time, insurance companies are shifting more and more costs to patients through higher premiums, deductibles, cost-sharing and surprise bills that come from these growing insurance gaps.

Often during an emergency visit, patients believe the facility they choose and physicians treating them are covered by their insurance plan. But because insurers are narrowing their networks, some facilities and doctors are out-of-network. This leads to a “surprise” medical bill for the patient. Patients are often shocked and upset (rightfully so) to find that the health insurance product they pay for is not providing the coverage it should. 

Virginia emergency physicians want to help patients by finding a solution for surprise insurance gaps. 

Working together, doctors want to:
• Protect patients from the surprise insurance gap
• Safeguard access to care by ensuring standards for network adequacy
• Improve transparency so that insurers make it easy for patients and doctors to know who is included in their narrow networks

For now, Matchett is grateful for the personal win, but she says the public is still at risk.

"Me and the rest of the public that has Cigna, if they go and have emergency services at an HCA Hospital, their doctors will not be covered," said Matchett.

Cigna says one way that you might protect yourself is to call the physicians billing office and try to negotiate a lower bill. Meantime, if you have an issue or complaint you'd like us to look into or help you with, Call 12 at 345-1212.

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