Still, more than a year after the conflict began, there’s no resolution.
The short run-down: UnitedHealthcare, which insures more than 1.4 million North Carolinians, and Providence Anesthesiology Associates, which has an exclusive contract to provide anesthesiology services for Novant Health’s Charlotte market, can’t come to an agreement on what PAA should be paid for its services. So, UHC kicked PAA out of its network. Now, any UHC patient who receives services from PAA is left with an out-of-network bill.
A variety of patients are being affected: Our first story focused on new moms who were blindsided by unexpected anesthesia bills for their epidurals. But this issue can affect anyone who needs any kind of anesthesiology service.
Take Jenna Wolbert. The 45-year-old mom is battling breast cancer during a pandemic as she also tries to engage her first grader in online learning at home.
She went in for a double mastectomy back in May. Soon after, she was hit with her first unexpected anesthesiology bill. Now, thanks to two hematomas and an infection, she’s four surgeries in, and estimates she’s up to $14,000 in anesthesiology bills.
“Every time I go into surgery, this is what I’m thinking of: my anesthesia’s not covered.”
And there are more surgeries to come. Her next two will center on an infected implant.
“(It) was devastating,” she said. “You go through all of this and you lose your breasts and you feel like you’ve lost your womanhood and you’ve lost any control that you might have had in any way.”
For Wolbert, the out-of-network feud between PAA and UHC has changed the way she approaches her care.
“The doctor was trying to avoid going back into surgery at all cost,” Wolbert said of avoiding surgery after her implant got infected. “We wanted to make sure we tried everything. So it’s kind of like, take that UnitedHealthcare, four days in the hospital, enjoy.”
So far Wolbert says she hasn’t reached any resolution with UHC in settling her unpaid bills. But other patients we’ve spoken to have. In some cases, the insurer has significantly reduced or fully paid anesthesiology bills.
Not everyone is stuck with the entire bill: Rachel Heath, a Novant patient who went through her second miscarriage this summer, has seen part of her bill reduced but may have additional bills coming.
Heath was told her surgery would be $1,400, including anesthesiology. So she was surprised to get a bill from PAA for just under $1,400 for anesthesiology alone. She says she’s frustrated about the lack of communication, especially since her procedure was planned.
“I did my due diligence, I went to an in-network doctor at an in-network facility. Three times I was spoken to about what it was going to cost to do this procedure, never once did it come up that there would be a possibility that the anesthesiologist would be out of network,” Heath said.
After receiving the bill, she called PAA multiple times to have the charge reduced. But she struggled to get anyone on the phone.
She describes the billing issue, after the already painful experience of a miscarriage, as pain on top of pain.
“I just want to move on with my life and get to the point where we can try again but there’s all these steps in between to get there, you just want it to be over with,” Heath said. “And for this issue to be lingering it’s frustrating because it’s already a painful event.”
After the Agenda’s original story was published, Heath decided to reach out to PAA again and immediately got someone on the phone. The office was able to file a claim with UHC on her behalf. Initially she thought UHC was going to cover the entire bill but then it got more complicated.
Heath later learned UHC had only covered her anesthesia bill at the Medicare rate, not the rate PAA charged. Now, she has a UHC field account manager negotiating with PAA on her behalf.
Communication issues: Patients such as Heath are being notified of the out-of-network change after their procedures or deliveries.
A lawyer who spoke with the Agenda for this story confirmed that healthcare providers aren’t required to alert patients to out-of-network status for non-emergency procedures.
The responsibility to research a doctor’s network falls to the patient. But with a provider like an anesthesiologist, which patients don’t personally pick, that’s almost impossible to do. Most hospitals rotate anesthesiologists through the day, and whichever one is on duty when you go into labor or have a surgery is the one you get.
In Novant’s case though, all of its anesthesiologists are from the same group, PAA.
Updates from UnitedHealthcare: UHC’s CEO of the Carolinas Garland Scott says North Carolina as a whole has higher anesthesia costs than most other states, and says PAA was charging more than the average North Carolina anesthesiology provider.
“North Carolina anesthesia costs are (first or second) when you look at the range. Those high costs are driven by a small number of anesthesiologists,” Scott told the Agenda. “In this case Providence is charging 13 times what Medicare would charge.”
Research from the Health Care Cost Institute backs the statewide claim. North Carolina is consistently higher than most other states when it comes to a variety of different anesthesiology services, including planned vaginal deliveries.
We also found, in looking at patient bills, that PAA’s rates, when compared to the averages shown by the Health Care Cost Institute and Fair Health, were higher than most.
Scott also says UHC has made multiple proposals to get PAA back in network, but says PAA has only come back with one formal proposal in their year of negotiations. UHC maintains that it pays PAA “market-competitive rates” for the services provided to members, and that PAA is the one, UHC says, that bills the higher rate.
“Our focus is on protecting the consumers in this process. We’ve made a payment on their behalf in the case of PAA and they’re billing on top of that,” he said of UHC paying a small portion of PAA patient bills. “We don’t understand the need to do that.”
Updates from PAA: Earlier this month, PAA chairman Dr. Jay Duggins talked to the Agenda and refuted many of the UHC complaints, including the one about being unresponsive. The group also maintains that its pricing is in line with other local providers.
The group also pointed out that UHC made $6.6 billion in the second quarter of this year.
The group sent a written statement in response to my request for an update:
“Providence Anesthesiology is fiercely opposed to the surprise billing practices of UnitedHealthcare and is working with out-of-network patients to minimize their financial burden. We are reaching out to affected patients to help them file appeals with United, and we’re not requiring any payments until each individual situation is resolved. At the same time, we are determined to get back in-network with United, and we urge people to call the North Carolina Department of Insurance at 855-408-1212 and ask them to demand UnitedHealthcare’s return to the negotiating table.”
PAA also noted that it’s not the only group that’s recently been kicked out of UHC’s network. A February study by the American Society of Anesthesiologists shows that 42 percent of respondents had contracts with insurance providers terminated within the last six months. The study named UnitedHealthcare as being associated with most of the changes.
Additionally, heath care providers in other states have filed lawsuits against UHC for deflating reimbursements.
Updates from Novant: We also reached out to a representative from Novant, who responded with a statement, saying in part:
“We strongly encourage UHC to come back to the negotiating table with Providence Anesthesiology Associates (PAA) to find a reasonable solution — and to do so quickly. We also strongly encourage PAA to continue to do what it can to ensure patients are not burdened with higher-than-expected charges for their services while negotiations are ongoing.”