Invisible providers are providers that people can not choose directly. They tend to fall under the PEAR specialties of Pathology, Emergency Medicine, Anesthesiology, and Radiology. PEAR providers are seldom in insurance company directories because people don’t choose their pathologist, they don’t choose who treats them at the ER, and they don’t choose who knocks them out when there is a surgery. Traditionally, most PEAR providers were employees of the hospital that they worked at, and thus they were in network at in network hospitals. Their charges would be part of the overall contract package between an insurance company and the hospital.
Over the past fifteen years or so, hospitals have been outsourcing their PEAR specialties to specialty provider groups. These groups are no longer bound by the hospital’s insurance contract, and they often resist being part of an insurer’s network because the typical insurance company threat that they’ll redirect members elsewhere is a hollow threat. A Par hospital will need someone to do their pathology and the insurer can’t mandate that pathology sample be sent 10 miles away to a par facility for a fast verification that the cancer is gone.
The PEAR providers are now out of network providers that can charge anything that they want which produces provider-insurer pissing matches and big bills for patients who thought that they did everything right in finding a par surgeon, a par hospital, pre-authorized the stay, and arranged for a relative to pick them up two days after a surgery with the expectation that they would max out their in-network deductible and owe nothing else besides parking.
Instead, the patient would max out their in-network deductible as expected but then get hit with a $10,000 pathology charge, and a $27,500 anethesiology charge that the insurance company would only pick up half as those are out of network providers. This is worse for HMO and EPO plans than PPO plans as PPO plans will pay something.
California is doing something about this:
A measure that would protect Californians from so-called “surprise” doctor bills cleared the Assembly floor on a 69-1 vote Tuesday.
AB 533, authored by Rob Bonta (D-Oakland), targets situations in which consumers get care at a facility that’s in their insurance network, but also receive services from a provider who is not in their network.
Bonta’s legislation would, in such circumstances, limit the amount a patient can be charged by an out-of-network doctor to no more than the amount the patient would have paid had the physician been in network.
The PEARs will cry, but this is a good idea.