If Medicare had been the payor in this case, the hospital’s total reimbursement would have been a little less than $2,000. But the lithotripsy and associated costs were billed at $33,160, or just under 17 times the Medicare rate. After the patient applied for financial assistance, a 30% contractual adjustment was applied, reducing her bill to just under 12 times the Medicare rate.
If the health system had asked her to pay 190 percent of Medicare – typically the upper end of commercial insurance rates – her bill would have been about $3,800. By the time I was contacted, the patient and her husband – responsible people trying to make good on their debt – had already paid the health system $5,700 or 285 percent of Medicare. The hospital insisted they owed an additional $16,000.
Section 9007 of the ACA took effect last year and prohibits excessive pricing for self-pay patients, and would revoke a charitable hospital’s tax-exempt status if it charges them more than it charges for insured patients. The language is ambiguous, conceivably allowing health systems to circumvent the law’s intent. But the spirit is clear. To keep their not-for-profit tax status and perks, health systems must stop taking advantage of self-pay patients."
While I disagree that the ACA has done anything to really address this, just lip service like it gave affordability, why should we tolerate anyone being subjected to this abuse? That is the failure of the ACA and why it has hurt affordability, not helped it. Small or out-of-state health plans have no more bargaining power, maybe even less, than an in-state resident. In fact, while there are already laws to protect the uninsured, there is no protection for health plans, and with considerably deeper pockets they are even juicer targets.
By capping out of pocket, mandating unlimited lifetime maximums and requiring services be paid at 100% the ACA has exacerbated this problem.