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Surprise medical billing is one of the most urgent topics in health care.

Too often after a hospital procedure or visit to an emergency room patients get hit with unexpected bills from out-of-network doctors they had no role in choosing. These include assistant surgeons, emergency room doctors and anesthesiologists.

Most research and media coverage focuses on how burdensome these bills are for the patients who receive them. As health economists and policy analysts, we think there is a broader impact of surprise billing that deserves to share the spotlight.

Eviden...

Aetna has been fined by California’s Department of Managed Health Care for denying emergency room claims against the state’s standards.

“The plan’s failure to follow California law for reimbursing emergency room claims is unacceptable,” said Acting DMHC Director Mary Watanabe. “This has resulted in Aetna wrongfully denying emergency room claims. Aetna must follow the state’s health care laws to ensure enrollees have access to the care they need.”

According to California law, health plans are required to cover emergency services. The only exceptions are if the he...

Franklin Walter went to Mercy Regional Medical Center for a routine knee replacement in April 2019. What he came away with two months later was a surprise bill totaling $1,216.73. Without an explanation or itemized statement, Walter found himself indebted to the hospital after believing his insurance would cover all the costs.

Surprise or inflated medical bills have fueled the push to reform the health care system in the United States, particularly in rural areas where care options are limited. One method of pushback against unexpected medical bills is the court sys...

The program, called “Health Reimagined,” ranges from expanded telehealth connections in rural Butte County to building out primary care in Monterey. New “community health advocates” in Los Angeles and elsewhere will help members with nonmedical needs, like housing and food assistance.

“We came to the conclusion that we couldn’t just incrementally improve on a system that’s fundamentally dysfunctional,” said Paul Markovich, chief executive officer of Blue Shield of California.

Even before the coronavirus pandemic began, physicians suffered from high rates of burnout a...

Thousands of Connecticut therapists say they aren't getting paid, even though they're seeing patients.

Before COVID-19, therapists said they would see their patients, file the claim with the insurance company Anthem Blue Cross and Blue Shield, and would get paid within a week.

Now, they said it’s been six weeks and they haven’t gotten their money.

Licensed Marriage and Family Therapist Rebecca Burton has been seeing her patients virtually, but says she isn’t getting paid for some of the services she’s providing.

“I don’t know if I’ll be able to pay my rent this month,”...

The behavioral health units of UnitedHealthcare and Cigna face four class-action lawsuits claiming the insurers conspired with a third-party company to underpay providers and balance bill patients hundreds of millions of dollars.

The lawsuits, filed by law firm Napoli Shkolnik April 5, accuse United Behavioral Health and Cigna Behavioral Health of using Viant as a middleman company to systematically lower payments to out-of-network outpatient providers for substance abuse and mental health treatment. The lawsuit alleges providers got less than 5 percent of what they...

Health systems and their associated employed provider networks are beset with immediate financial losses, and future financial uncertainty as elective care was essentially eliminated by the COVID-19 (coronavirus) pandemic in the United States.

Approaching the situation through a defined checklist may afford healthcare leaders an ability to step back and rationally review options during this challenging and tumultuous time. 

Background

In the wake of President Trump’s National Emergency declaration on March 13, 2020, multiple health experts and agencies, including the...

A Chicago affiliate of health insurer Anthem won't yet be able to escape a lawsuit accusing it of improperly and regularly rejecting coverage claims, allegedly violating Medicare rules.

However, a federal judge said Anthem itself shouldn't be held accountable for the affiliate's actions.

The decision was issued March 26 by Judge Jorge Alonso, of U.S. District Court for the Northern District of Illinois. 

Alonso’s ruling kept Chicago-based American Imaging (AIM) in a suit brought in 2015 by a former employee, Dr. Susan Nedza. However, Alonso cut loose AIM’s parent comp...

San Jose Neurospine is battling Aetna Health California in court, alleging that the insurer illegally refused to pay for emergency medical services performed by spine surgeon Adebukola Onibokun, MD, the practice's owner.

What you should know:

1. The case centers on a two-level lumbar microdiscectomy that Dr. Onibokun performed in April 2017. San Jose Neurospine submitted two claims to Aetna for reimbursement — one for emergency medical services and one for nonemergency surgery. Aetna only provided payment for the latter.

2. San Jose Neurospine filed a civil action aga...

One in five patients who get elective surgery at U.S. hospitals that accept their insurance may still get surprise medical bills, especially if they receive anesthesia, a new study suggests.

The study looked at what happened to almost 350,000 patients who had non-emergency surgery between 2012 and 2017 at hospitals and clinics that belonged to their health plan network, using surgeons who accepted their insurance.

Even among those who did their best to go where their insurance was accepted, 21% still got surprised by out-of-network bills. And tabs were not small, ave...

Two physicians specializing in ophthalmology recently paid the federal government nearly $949,000 to resolve allegations that they violated the False Claims Act, according to the Department of Justice.

The settlement resolves allegations that Mark Smith, MD, and Fane Robinson, MD, physicians at San Diego Retina Associates, submitted false claims to Medicare. They allegedly submitted claims for care provided by a physician who was not properly credentialed to render care to Medicare patients.

The government further alleged that Drs. Smith and Robinson submitted claims...

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