Bamboozled: A doctor's perspective

This is an open letter posted in response to a Bamboozled column that appeared in The Star-Ledger on June 5, 2017.

As an orthopaedic hand surgeon and president of the New Jersey Doctor-Patient Alliance, I live and breathe these issues on a daily basis.

I am disheartened in the way this article seems to cast doctors as nefarious agents of the medical community. On the contrary, my colleagues and I take extreme pride in the care we deliver to our patients, as we have devoted the majority of our lives toward helping people at their most vulnerable and stressful moments.

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The truth is, the "surprise" medical bills in this article have nothing to do with the doctors and nearly everything to do with the behavior of Horizon.

The article accurately reflects some patient/consumer assumptions about doctors that we are trying to bill patients unreasonably for services not provided.

In reality, the time we spend speaking to and examining our patients is typically only a fraction of the time we spend processing, formulating, and documenting a proper assessment and plan.

From there, bills for our services are sent directly to the insurance company, which commonly delays, discounts, or denies our reimbursement. What happens next is the genesis of the "surprise bill," created when the insurance company doesn't live up to their end of the bargain.

The article and previous ones like it have placed a disproportionate amount of blame on doctors for surprise bills, when in actuality, these are usually the residue of insurance company shenanigans.

For proof, look no further than the fact that these stories invariably end with the insurance company paying that surprise bill. I can assure you its not because they are trying to be nice, but because they were supposed to pay the bill in the first place. Despite this, the negative media slant doctors receive surrounding this issue has stoked a palpable distrust between doctors and our patients.

Regarding the specifics of the article, I would like to clarify several misconceptions.

First, none of the doctors in the article are "out-of-network," as the headline says, but are all in fact in-network with Horizon. With the debut of Horizon's Omnia plans in the beginning of 2016, an already confusing insurance landscape got even messier and less consumer-friendly.

With Omnia, Horizon decided to take their large, uniform network of doctors and divide them into 2 "tiers." The premise was that if a patient had an office visit or a service provided from a Tier 1 doctor, only a minimal co-pay/deductible would apply, whereas if they saw a Tier 2 doctor for the same service, that same patient would have a larger co-pay/deductible.

This was obviously designed to have patients preferentially seek out care from Tier 1 providers. Sounds logical, right?

But let's think of it for a moment from the doctor's perspective. Prior to 2016, you were either part of Horizon's network, or you weren't. If you are a doctor who accepts Horizon, you have signed a contract to be part of their in-network doctor panel in exchange for accepting a steeply discounted reimbursement rate for your services.

If you are okay with this, though, it is only for the exchange of having patients being preferentially driven to you (fewer out-of-pocket costs for them). Then, one day, you get a letter from Horizon introducing you to their great new plan called Omnia, except that your letter says you have been assigned as a Tier 2 doctor in this new plan.

There is no explanation, no course of remedy, and no path laid out to become part of Tier 1. Horizon has effectively given you, the doctor, an "out-of-network-like" status within a network you had originally joined in good faith to be a preferred provider.

This system reminds me of the Orwell quote, "All animals are equal, but some animals are more equal than others." This is not a very fair proposition from a Horizon Tier 2 doctor's perspective.

And as confusing as this whole insurance situation is for the media as well as the medical community to understand, the average Omnia subscriber has no shot at keeping up with these different Tiers and the different levels of co-pays for every different type of visit, out-patient, in-patient, emergency, ambulatory surgical centers, etc, etc.

In this morass of manufactured confusion, a ripe opportunity for an insurance scam has been born. This passage in the article was alarming:

"Some (bills) were overturned, she said ... , because some Tier 1 doctors were mistakenly billed as Tier 2 doctors. "

Maybe this is just a coincidence, a clerical error, or just a misunderstanding. But it seems to me that if anyone should know who is a Tier 1 vs a Tier 2 provider, its Horizon...it's their Frankenstein.

So is it possible that Horizon could be routinely charging their subscribers Tier 2 copays and deductibles even when the are seen by Tier 1 doctors in emergency rooms? At a couple hundred dollars, many people in this day and age wouldn't think twice about a bill less than $200, and would pay it, trusting that the insurance company is keeping track of this confusing Omnia system for them.

Could this article have given us a tiny glimpse behind the curtain of an Omnia insurance scam that is potentially defrauding thousands of subscribers? If there are more Ms. Andersons out there, there may be a larger story to tell.

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