Frank Lacks, 51, suffered from intense abdominal pain, so he went to his local emergency room at the Aurora Medical Center. He felt confident his Blue Cross Blue Shield insurance would cover the trip.
It turned out he needed to have a gallstone surgically removed. After the procedure came another uncomfortable surprise. While his insurance would cover his four days in the hospital, his plan did not cover emergency care. So, he got stuck with a sizable out-of-pocket bill he could not afford.
“I gave them my insurance card,” said Lacks. “They should have called my insurance company and said, ‘We don’t have someone in network. Will you still pay?’ Or they should have given me the option of going to another doctor or another hospital. Now, I get a bill for $1,300. I have enough problems in my life.”
A doctor turned senator responds
Lacks owns a limo company and regularly shuttles politicos around the Denver metro area. When he got to chatting with some of his clients about the surprise bill and the court order to pay it, the pols recommended that he reach out to Sen. Irene Aguilar, D-Denver. A physician herself, Aguilar had become increasingly concerned about how medical providers bill for some kinds of out-of-network care.
Lacks wasn’t the first Coloradan to come to Aguilar with this problem. Several have reached out to her, some with “surprise bills” from planned surgeries that exceed $100,000.
“When you’re doing the right things — getting insurance and paying your premiums — I don’t think you should be hit by a surprise bill,” Aguilar told The Independent. “It’s not fair and in some cases I think it’s unethical.”
Aguilar has put together a bill, SB 259, with the goal of protecting patients like Lacks. If the bill passes, it would require doctors to warn patients when insurance won’t cover their care.
Though Colorado law requires that insurance plans regulated by the state cover emergency cases like Lacks’s, plans with only federal oversight don’t have to include the same protections. Lacks is in this latter category.
The Aurora Medical Center said the issue is more complicated than it appears. Staff treats everyone who comes to the ER, regardless of insurance status. The Center strives to be in-network for as many plans as possible but it can’t honor every plan.
“It makes me feel terrible. I mean what do you expect me to feel? I have insurance and I’m being charged out-of-pocket. It makes me feel like I’m being ripped off,” said Lacks. He still owes the hospital $700.
Clash of the doctors
Dr. Tamaan Osbourne-Roberts, the president of The Colorado Medical Society, strongly opposes Aguilar’s bill.
“One of the biggest assumptions in the bill is that the doctor will in every instance know the type of plan the patient has and whether the doctor participates,” said Osbourne, pointing out that there are hundreds of different plans. He also said it would be awkward for a doctor to ask about a patient’s coverage on first meeting, particularly if the patient was in an urgent and painful situation.
“It puts the consumer in a bad position because they’re in the position of making a last-minute choice about care they feel they need,” said Osbourne.
The Medical Society also clashes with Aguilar on some of the more technical aspects of the bill. For instance, it would change how providers charge for out-of-network care when insurance companies are legally required to cover it. In those cases, Aguilar’s bill would limit how much providers can charge insurance companies to their area’s average in-network price.
The Medical Society says this gives too much power to insurers. Aguilar says, it is fair to patients and the insurers who cover them.
“I’m a doctor. My husband’s a well-paid doctor, It’s not my intention to screw doctors,” said Aguilar, contending that her bill is primarily about consumer protection and that patients, like Lacks, want the chance to make an informed decision.
The measure will come up for public hearing later this month.
Emergency Room by Thierry Geoffroy, PS1 / MOMA in 2007