A Hollister resident experienced sticker shock when she received
a Blue Cross statement last week for an April visit to the Hazel
Hawkins Hospital emergency room.
The
”
explanation of benefits
”
stated her family would be responsible for $301 out of $437
billed for treatment of her son’s inflamed sinuses. The document
stated the physicians group contracted at the hospital emergency
room
– California EM-1 Medical Services – was a
”
non-participating provider.
”
A Hollister resident experienced sticker shock when she received a Blue Cross statement last week for an April visit to the Hazel Hawkins Hospital emergency room.
The “explanation of benefits” stated her family would be responsible for $301 out of $437 billed for treatment of her son’s inflamed sinuses. The document stated the physicians group contracted at the hospital emergency room – California EM-1 Medical Services – was a “non-participating provider.”
The woman, who requested anonymity, took the statement to mean the hospital did not accept the rates of Blue Cross – the largest medical insurance provider in the state.
A call to Ken Underwood, the chief administrative officer with the hospital, assured her the doctors did accept Blue Cross rates, but the notification ignited concerns by Underwood that the confusion went beyond that one patient.
Underwood said that anyone else with Blue Cross who had used the emergency room during the past few months may have also received the same misleading information.
“I would encourage everyone to review all of their billings,” Underwood said.
Furthermore, Underwood said the problem may exist statewide.
“To my knowledge, Blue Cross is sending it to every patient seen by EM-1 throughout the state,” he said.
Whenever residents receive emergency room treatment, their insurance company routinely sends an explanation of benefits. The document – which officials say is not a bill – states whether the hospital provider is “participating,” “non-participating” or “out of network.”
It also, however, includes dollar amounts relating to those classifications that confused at least one customer. The resident’s bill stated: “It is your responsibility to pay: $301.26.”
But she, in fact, was not accountable for that amount. Blue Cross said it provides the statements to inform customers of the amount for which they are liable – regardless of the actual billing invoice, which comes from the doctors group.
Blue Cross and California EM-1 Medical Services – which employs doctors at about 50 emergency rooms throughout the state – do not have a contract. That is why the doctors group is classified as a non-participating provider. Both parties, Underwood said, “have been diligently pursuing” an agreement for the past five years.
Regardless, EM-1 doctors at the local hospital do accept Blue Cross rates, said Underwood, who called the fees “significantly lower than our average contract.”
The amounts are essentially what Blue Cross is willing to pay hospitals for treatments received by insurance carriers. Blue Cross, according to Underwood, “dictates what they pay.”
“There’s no negotiating with Blue Cross,” he said.
EM-1 accepts the lower Blue Cross rates at Hazel Hawkins Hospital because the impact without the special agreement would affect medical costs in the community and cause many people to “go elsewhere,” Underwood said.
The public hospital currently has contracts with about 25 different insurance companies, but nearly 30 percent of the hospital’s patients carry Blue Cross.
Underwood called the wording in the explanation of benefits a “scare letter” to patients.
“They (Blue Cross) are trying to play hard ball – to get (EM-1) to sign a contract,” he said.
Blue Cross, however, denied the allegations.
“Absolutely not,” said Michael Chee, Blue Cross of California director of corporate communications. “It’s standard language.”
Chee emphasized that the explanation of benefits received by the Hollister resident was not a bill or a scare letter.
Underwood has been in contact with officials from EM-1 during the past two weeks and sent a list of all patients carrying Blue Cross who, since April, have visited the local emergency room. He said an average of 1,200 people a month, regardless of insurance coverage, come to the emergency room.
The doctors group, according to Underwood, plans to send letters to all the patients with Blue Cross advising them that the hospital accepts Blue Cross rates. The letter will emphasize that people should review their bills carefully to assure they are not being over-charged. Moreover, EM-1 plans to place advertisements in Hollister newspapers stating the same cautions.
EM-1 also recently added to its invoices – just those sent to Hazel Hawkins Hospital patients – an explanation of the special agreement in Hollister, according to Gina Capone, EM-1 client operations manager.
While Blue Cross plans to continue sending the explanations of benefits, including the “non-participating provider” language and liability, Capone said the insurance company is “telling the truth.” She said EM-1’s non-participating provider status legally warrants the relatively high dollar amounts on those notices.
Until the two parties reach a contract agreement and EM-1 becomes a participating provider, doctors will continue, as Capone called it, “working with the hospital and the community.”
“Patients get stuck in the middle, they really do,” she said. “Insurance companies really penalize the patients if the providers underneath the hospital are not participating.”
Underwood said any patients who are concerned or suspect inaccurate billing should call or fax him at the hospital. The phone number is 636-2670 and the fax is 636-2668.
“I don’t want patients to think they can’t use the E.R.,” Underwood said. “That’s bad service to the community. I’ve always accepted what Blue Cross pays.”
