KANSAS CITY — Chris Costantini lay in a cold sweat, his shoulder dislocated after slipping on a porch in Kansas City, Kansas.
He’d been out alone, knocking on doors and rustling up voters for the upcoming midterms in October 2018. Now he waited for an ambulance, full of anxiety about how the injury could hinder his next performance at the Kansas City Ballet.
A different anxiety only began later, when the bills rolled in. That ambulance, it turned out, didn’t fall in his insurance network. So Costantini found himself on the hook for a $900 bill.
He tackled that and the ambulance in more manageable monthly increments, counting his blessings that he could afford it.
“Perversely, I feel lucky,” Costantini said. “You would think that we wouldn’t have to feel lucky.”
The logic fails
Patients often don’t realize they’ve received out-of-network services until an extra bill arrives from a provider they never chose.
“The anesthesiologist is who’s on call when you show up,” said Karen Pollitz of the Kaiser Family Foundation. “If you’re having cancer surgery, you’ll never meet the pathologist who looks at your slides.”
Laura Burton made the common assumption that the doctors walking the halls of her in-network hospital in Topeka work for that hospital and fall in the same network.
“Absolutely,” she said. “One hundred percent, that’s what I believed.”
Then came a letter from a Michigan mailing address demanding $400 for a pediatrician employed by an external staffing firm who checked on baby Amelia, soon after her 2014 birth.
“It was not something we could pay off off-hand,” Burton recalled. “Who would ever anticipate that a random physician would come in who wouldn’t be covered?”
People like Burton in Topeka have done things right, said Jack Hoadley, a health policy researcher and professor emeritus at Georgetown University. They got insurance and went to an in-network hospital.
Yet none of that helps if the pediatrician who pops by has no deal with your insurer.
Experts warn that some providers — such as hospital staffing companies backed by private equity funds — avoid joining networks to cash in on the lucrative world of surprise billing. That lets them charge more than the rates negotiated by insurance companies.
A Stanford University analysis of millions of insurance claims found more than 80% of ambulance rides fell outside patients’ insurance networks. New research from Yale University, meanwhile, estimates that reining in out-of-network billing by anesthetists and others could cut health care spending by tens of billions of dollars annually.
Meanwhile, 25 states have refused to wait for a federal fix. They’ve passed some level of consumer protections against surprise bills.
Kansas hasn’t. And though it might be especially useful in a state where the ACA health exchange offers only plans that are particularly unhelpful for out-of-network care, advocates say action in Washington, D.C., is the ideal.
State laws can’t help most people with private insurance through work, for example. Only changes to federal law can.