A flood of surprise hospital bills could start arriving in U.S. mailboxes as early as January unless two giant for-profit health care companies resolve a dispute over whether thousands of doctors remain in patients’ insurance networks.
America’s biggest health insurer, UnitedHealthcare, is pitted against one of the country’s largest employers of doctors, Envision Healthcare, in a massive contract fight over prices that Envision’s 25,000 emergency doctors, anesthesiologists and other hospital-based clinicians charge.
A contract impasse would mean that UnitedHealthcare’s 27 million privately insured patients could face expensive, unexpected doctor bills as of Jan. 1 when Envision doctors would become out-of-network.
Envision has already been criticized for its billing practices in situations where its doctors don’t participate in patients’ health plans. A Florida man got a bill for $2,255 from an Envision subsidiary after being treated by an out-of-network emergency doctor in 2014 for a facial injury, according to a lawsuit he filed earlier this year.
In another case, a California woman went to an in-network hospital for abdominal pain and found she needed emergency gallbladder surgery. The operation was covered, but she faced $4,447 in bills from Envision for two trips to the emergency department.
A judge dismissed the Florida case, and the case in California is in settlement talks.
“With emergency-room docs, patients don’t have any control, don’t have any ability to stay in a network,” said Paul Ginsburg, a health economist and director of the USC-Brookings Schaeffer Initiative for Health Policy.
The standoff comes as patients and policy makers are increasingly fed up with unexpected medical bills and soaring insurance expenses that can sink a family’s finances. More than half of Americans have gotten an unexpected medical bill, according to an August survey by the research group NORC at the University of Chicago. About 1 in 5 emergency-room admissions resulted in a surprise out-of-network bill, economists from the Federal Trade Commission reported in 2017.
“With emergency room docs, patients don’t have any control, don’t have any ability to stay in a network.”
Insurers contract with networks of doctors and hospitals to negotiate how much they will pay for their members’ medical care. In many health plans, patients can still see doctors outside of that network, and the insurer will often pay some portion of the bill. But out-of-network providers are free to try to collect the rest of their charges from patients directly. That practice, known as balance billing, has enraged consumers and drawn scrutiny from regulators.
Several states including California, Florida, and New York tried to restrict the practice. Both Republicans and Democrats have sponsored federal legislation this year to limit charges for patients when hospital doctors are out of network.
Big money is at stake. Envision gets about $1 billion in annual revenue from UnitedHealthcare, the company says. Its total revenue last year was $7.8 billion. UnitedHealthcare said about 650,000 of its members received care from Envision clinicians last year.
Both companies have been trading blame for the hit patients will take if they don’t reach a deal over the terms of reimbursement, though both sides remain hopeful about reaching agreement. While stand-offs between insurers and medical providers are common, the stakes are especially high in this one because of the size of both companies and the fact that patients have little ability to avoid Envision's doctors in emergency situations.
The conflict has been heating up since October when UnitedHealthcare published a letter it sent to hospitals warning that an impasse could leave their patients dissatisfied “from higher out of pocket costs and patient confusion.” It also set up a website accusing Envision of “price gouging” with charges double the average for emergency services.
“We remain committed to working with Envision in finding a solution that will renew their participation in our network at rates that are affordable and predictable for the customers and members we serve,” UnitedHealthcare spokesman Stephen Shivinksy said in an email.
Envision blames insurers for gaps in coverage that leave patients exposed. "We’re just not understanding why United is interested in pushing a large emergency group out of network,” Bob Kneeley, a spokesperson for Envision, said.
Envision is one of a handful of big medical staffing companies that supply emergency doctors, anesthesiologists and other clinicians to hospitals nationwide. Physician-staffing companies can help lower costs for hospitals and bring doctors to areas where hospitals may struggle to find qualified staff.
The company was built through a series of acquisitions, culminating in a 2016 merger with AmSurg, a large surgery center and physician staffing group. In October, private equity giant KKR purchased the combined company for $9.5 billion, including debt.
Envision bills independently from the hospitals where its doctors work. That arrangement means that even patients who choose a hospital in their health plan’s network may face charges from Envision's physicians who don’t take their insurance.
Since its merger with AmSurg, Envision has been trying to shake off a reputation for aggressive billing practices that it contends is undeserved. AmSurg Chief Executive Officer Christopher Holden took over at Envision after the companies merged two years ago. He soon pledged to change course. “We are focused on moving the majority of our relationships to in-network status,” he told investors in February 2017, on his first earnings call leading the combined company.
The roots of the dispute with UnitedHealthcare go back to 2009, when a Florida physician group called Sheridan Healthcorp signed a multi-year contract with the insurer. Through a series of acquisitions, Sheridan became part of what is now Envision Healthcare, bringing more and more doctors under the umbrella of that contract.
That contract surfaced in a lawsuit that Envision filed against UnitedHealthcare in March, a case that offers a rare look at the behind-closed-doors maneuvering that determines medical prices.
According to Envision's lawsuit, UnitedHealthcare failed to pay newly acquired medical groups under the contract as Envision expanded its footprint. Envision said that decision “hurts patients financially, while saving UnitedHealthcare money at the patients’ expense.”
UnitedHealthcare countered in legal filings that “the addition of Envision and its numerous subsidiaries served to drastically expand the scope of specialties far past those originally contemplated” by the contract. The insurer also accused Envision of “an improper game of hide-the-ball” to boost profits without proper notice of price hikes. The lawsuit was sent to private arbitration, which is ongoing.
Price hikes were part of the playbook for Envision and its predecessor companies. Agreements with large insurers typically lasted several years and “often provide for annual increases in reimbursement rates,” according to AmSurg’s 2015 annual report.
A redacted copy of the disputed 2009 contract shows that UnitedHealthcare originally agreed to pay 80 percent of eligible charges. That’s a structure insurers typically try to avoid, because medical companies can set their charges as high as they like. “It’s very strange,” said Ginsburg, the health economist. “Insurers, if they’re negotiating, they want to negotiate a link to a hard number.”In November, after Bloomberg News inquired about the document, the companies asked the court to refile a copy of the contract with additional information withheld, because the original filing “inadvertently omitted” to black out the contract rate the companies agreed on.Both companies declined to comment on the earlier agreement.
If the companies remain at an impasse in January, UnitedHealthcare will be under pressure to shield its members from Envision’s bills, Ginsburg said, because it has little ability to steer patients to other providers.
UnitedHealthcare has said it will set up a hotline for patients to report unexpected charges from Envision and advocate dropping those charges. Envision’s Kneeley said the company preferred to remain in-network, but either way it expects to get paid.
“We’ll continue to see the patients, and then we’ll continue to seek reimbursement,” he said.