Balance billing is controversial, and there are two sides to the issue, but it has the net effect of causing certain victims, in certain states, to be faced with enormous bills.

This is again, an American issue, and again will leave the rest of the world wondering how we ever managed to get ourselves into such a dysfunctional situation.

Most Americans under 65 are enrolled in PPO’s or HMO’s. These are similar in they involve a predefined network of providers, which the person insured is required to use if he want to be covered. Now most would agree that if someone elected to use an out of network provider that it would be reasonable that they had to pay for it. But the key word here is “elected.”

Suppose you are in an automobile accident, unconscious, and taken to a hospital for emergency treatment. Now, you will be treated. By federal law, if the hospital accepts Medicare, and virtually all of them do, they must accept emergencies.

But the medical personnel who treat you are not necessarily in your PPO or HMO network. Now what?

Let us suppose you need emergency surgery. You might well encounter doctors, anesthesiologists, etc. who are out-of-network. You are hardly “electing” these people. You may be out cold. You would hope they would bill at some reasonable price, and many of them do.

But if they are out of network, they don’t have to. They can charge what they want. And some of them inflate their fees enormously. It has been reported that some have actually billed at a hundred-fold the Medicare price. Now to stick it to someone that is already the victim of an accident is so removed from any behavior that one would expect from one’s fellow human beings, much less health care providers, is in a moral sense, a little hard to get a handle on. It certainly requires a very narrow interpretation of the first item of the Hippocratic oath: “Do no Harm.” But such medical practitioners are apparently out there.

It is unclear how much of a problem this actually is. Certainly in the case of elective procedures, a nose job for instance, there would seem to be little need in controlling the price. Market forces will prevail there. So the main place for abuse would appear to be emergency services.

There are laws. A state by state list can be found here. Every state, plus DC, has its own particular version.

All states but one have some sort of law that prohibits managed care providers from billing managed care enrollees (PPO’s and HMO’s) for covered services. Only Alaska has none. In all the other states, an enrollee in an HMO cannot be balanced billed for covered services performed by an out of network provider. However, for PPO enrollees, such protection is offered only in 28 states, but not 23 others. There seems to be no political bias to it. Mississippi and California offer it, New York and Alabama do not. See the list for your own state’s rules.

Since protection of HMO enrollees seem to be almost universal, why aren’t PPO enrollees protected as well. We don’t know. Does anyone out there in blog-land know why this is?

And why isn’t there a federal law governing all this, along with the egregious inflated list prices for various other medical services. It is only reasonable that emergency services should be affordable, and not a profit center for the hospital and some of its doctors. But this is not the case. Such overpricing prohibitions needn’t extend to elective out-of-service providers. There is no need to regulate pricing for a celebrity plastic surgeon. Emergency services are a completely different story.

Collusions have been reported. One goes like this. In a planned and supposedly covered surgery, a covered surgeon will call for an assistant surgeon who is not a network provider, and who will subsequently bill the patient some enormous amount. That this could be a widespread practice seems very unlikely. Actual collection of such an amount would be doubtful, and if collusion were ever proven, both doctors would likely lose their licenses. This would be risking a lot for a little. Perhaps there are laws prohibiting this. The stories seem anecdotal.

And Medicare? Medicare enrollees cannot be balanced billed. So that’s that. If you are a Medicare enrollee, you may wonder why we made you read this far. Sorry. Won’t happen again.