Texas Spanks Humana – Who’s Gonna Pay For It?

Now let me get this straight. Humana tries and fails to negotiate a reasonable rate with enough in-network providers and is punished for it. Well, the solution is to get rid of the network and treat all providers as out-of-network. That’s what Reference Based Pricing plans do.……………..BTW guess where Humana is going to get the $700,000………………………..

– Bill Rusteberg

Texas fines Humana for lack of in-network anesthesiologists

Samantha Liss

Dive Brief:

  • The Texas Department of Insurance has fined Humana $700,000 for failing to maintain an adequate network of anesthesia services for its plan members in three of the state’s largest metropolitan areas, the department said Monday.
  • The state found that more than 20 hospitals and surgical centers lacked in-network anesthesiologists, putting patients at-risk of higher out-of-pocket costs.
  • Humana and the Texas Department of Insurance agreed to a consent orders outlining the corrective action the health plan must take. “Humana has agreed to process these as in-network claims. Not one Humana consumer will pay extra because of this network issue,” Insurance Commissioner Kent Sullivan said in a statement.

Dive Insight:

The issue of out-of-network physicians providing care at in-network facilities and potentially exposing patients to massive bills has persisted throughout the country despite outcry from the public.

There are few protections in place to shield patients from surprise or balance billing.

A 2017 Commonwealth Fund study found that most states don’t have laws in place to directly protect consumers from these types of bills. Many in the commercially insured market are covered by self-funded plans, which are regulated by federal law and not by states that may enact protections.

As health insurance networks contract and become more narrow with limited in-network facilities and physicians, the problem becomes more acute. For years, patients from all over have described a similar tale when they encounter an out-of-network provider at an in-network facility.

Most recently, UnitedHealthcare, the nation’s largest commercial insurer, threatened to drop Envision Healthcare, the largest provider of emergency services, from its network. The two have failed to come to an agreement over rates. The problem is that Envision employs many physicians throughout hospital facilities across the country, and with those physicians out-of-network, it could expose patients to higher cost.

The issue in Texas potentially exposed many Texans to exorbitant bills. Humana is the fourth largest health insurance writer and ninth largest HMO in the state, according to the Texas Department of Insurance.

Humana failed to adequately warn its members of the termination in anesthesiologist contracts that resulted in some to become considered out-of-network. Some members received balance bills, according to the department, which said it learned of the issue after receiving a tip from an anesthesiologist in Austin at the beginning of August.

Top image credit: CCO Public Domain Free for commercial use No attribution required Graphicstock

 

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