Judge rules Franklin Lakes parents must pay surprise out-of-network medical bill

Brenda Cristiano, who lives in Franklin Lakes, chose the hospital and her obstetrician because they participated in her insurance plan, Cigna. But when she needed an emergency cesarean section to deliver GianLuca in October 2014, none of the anesthesiologists at the hospital accepted Cigna.

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“Neither the patient nor her surgeon was allowed to choose the anesthesiologist,” a letter drafted by Valley to help with Cristiano’s insurance appeal said. “There was not an anesthesiologist available who participates with her insurance plan.”

The anesthesiologist, Dr. Sujnani Adokoli, is part of Bergen Anesthesia Group, which has an exclusive agreement with Valley to provide services. The group does not participate in Cigna’s network.

Judge Keith A. Bachmann said in his decision that the anesthesiologist’s bill — for $3,300 — was reasonable, though it was more than twice what Cigna paid, based on its typical reimbursement to in-network anesthesiologists. He ruled that the Cristianos owe the balance of $1,852.

The Cristianos say they can pay it but were fighting for principle.

Specialists who practice at an in-network hospital should accept the rates their patients’ insurance pays, even if they’re not in the insurer’s network, they said. Or Valley should require its staff and specialists to accept every insurance plan the hospital does.

Insurance companies negotiate contracts with doctors and hospitals to create networks that funnel patients to in-network providers in exchange for discounted fees. But patients often receive care from hospital-based physicians — including anesthesiologists, radiologists, pathologists, emergency-room doctors and neonatologists — who are out-of-network for their insurance, even when they go to an in-network hospital. The patients have no choice over which of these doctors provides their care. When these doctors bill the patients for amounts beyond what their insurance has paid, surprise medical bills result.

Doctors contend that staying out-of-network is the only way they can counter the power of large insurance companies, saying their in-network rates are too low and that they often deny or delay payments. But insurance companies say it drives up the costs of insurance for everyone when they are forced to pay the higher charges of out-of-network doctors and hospitals.

Legislation stalled

A measure introduced last spring in the state Legislature — which stalled in the face of strenuous opposition from doctor and hospital interest groups — is intended to prevent situations such as the Cristianos faced. Its sponsors hope to advance the measure this fall.

It would require hospitals that are in-network with a health plan to make sure that all of the providers caring for a patient in an emergency bill the patient no more than any deductible, coinsurance or copayment the patient would owe if the service were in-network. The providers could bill the insurance company more than the in-network rate, but disputes would be resolved through a system of binding arbitration.

The legislation was introduced by three Assembly Democrats — Craig Coughlin of Woodbridge, who is chairman of the committee in charge of insurance; Gary Schaer of Passaic, who heads the Budget Committee; and Troy Singleton of Mount Laurel, along with Sen. Joseph Vitale, chairman of the Senate Health Committee.

They acted in response to dozens of consumer complaints about surprise bills from doctors over whom the patients had no choice. Out-of-network neonatologists at Valley have billed patients thousands of dollars for the care of premature infants, as have surgeons who provided emergency care to patients at Hackensack University Medical Center.

Testimony heard

After the Cristianos’ appeals to Cigna for additional coverage were denied, Bergen Anesthesia sent its bill to a collections agency and filed suit in Superior Court in Hackensack. The judge heard testimony on July 30 from Brian Cole, Bergen Anesthesia’s practice manager, and Dr. Jeffrey Magnes of the group, as well as Anthony Cristiano, Brenda’s husband. Bachmann rendered his decision later that day, but the couple were not informed of the decision until this week.

“The bill was in accord with billing practices of other anesthesia providers in Bergen County,” the judge wrote. “But for the insurance plan that the defendant selected, the plaintiff’s bill would have been fully paid.”

The family is insured through Anthony Cristiano’s job with a large multistate firm, and the plan is governed by federal, rather than state, law. New Jersey law requires insurers to cover emergency services by out-of-network providers and leave patients with no obligation beyond their regular out-of-pocket costs. But federal law does not.

Valley provides a consent form to patients when they are admitted, and that also became an issue in the trial.

The form explains that some doctors involved in patient care at the hospital are not hospital employees and may not accept the same insurance plans the hospital does. It notes that the patient will receive separate bills from the hospital and other professionals and is responsible for both.

Anthony Cristiano wrote “Do Not Agree” across that section of the form.

That didn’t matter, the judge’s decision said, because the form is not a contract.

The patient “may believe that she informed the Valley Hospital that she did not agree to accept services” from doctors who are not in her insurance plan, Bachman wrote, but that “does not mean that [she] can dictate which medical group may provide services to her while at The Valley Hospital.”

Bergen Anesthesia said no one was available to comment on the decision Friday.

New push planned

This fall, the sponsors of the stalled bill say they plan to listen to different interest groups and push a consumer protection measure forward.

Physicians have said that the problem is with insurers, who they say pay too little to attract specialists to join their networks and then sell policies with inadequate reimbursement for out-of-network care to their customers.

The state’s largest insurer, Horizon Blue Cross Blue Shield of New Jersey, says out-of-network charges add $1 billion to health care costs in New Jersey. A bipartisan state commission recommended enactment of the legislation, estimating that it would save between $22 million and $98 million in insurance costs for state and public employees alone.

[Original article]