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A recent need for a CT scan left me with a clean bill of health, but a lingering pain in my wallet – and my psyche. Following the test, I learned the radiologist who interpreted the scan did not participate with my insurance provider, Blue Care Network, leaving me with a significant and unexpected bill – surprise!

As the CEO of a physician organization (patient care organization as I like to call it now), I’m well-versed in credentialing, health plan enrollment procedures, and hospital privileging – not to mention physician fees and billing practices. And I never bemoan a healthcare professional being paid fairly for the services they provide. Yet, as a patient, I don’t understand why the hospital didn’t tell me or my spouse in advance that a member of their staff, the radiologist, does not participate in my health plan. After all, the physician’s application went through a credentialing committee – and I have been under the impression that the staff credentialing process includes verifying whether the physician/healthcare professional participates with the same insurance plans the hospital does.

It’s rare today that one must not surrender health insurance information at the time an appointment is made, or prior to being admitted to the hospital. With all the data available in healthcare, it seems a quick check (hospital staff credentialing information or payer information), could reveal whether the radiologist that interprets the scans accepts my insurance.

That’s just one issue, though. I’m frustrated that a specialty physician would not accept a widely known and respected Michigan-based health insurance plan that covers tens of thousands of people in our state. It strikes me as much as a moral and ethical decision as it does an insurance decision. As our organization and others in the state purposefully turn our efforts to community-based care and the need for consideration of the social determinants of health, is there a moral imperative for physicians to support these efforts when possible through a practice as basic as participating with the area’s major health plans? Ah, but the reimbursement isn’t high enough you say! And that’s where the ethical decision arises.

Surprise or “balance” billing should be addressed by healthcare societies in addition to our legislature. Untreated, it can lead to financial toxicity,
reduced quality of life and, equally disturbing, limited access to medical care.

Surprise billing is unfair and unjust, and should be eliminated from the U.S. health care system. Some states have already enacted balanced billing protection acts to prevent people from getting a surprise medical bill, and Michigan has legislation pending, but only Congress has the power to effectively and comprehensively fix surprise out-of-network bills. Congresswomen Elissa Slotkin and Haley Stevens – can you help us out here?