Donelon: Cover specialists

• By TED GRIGGS
• Advocate business writer
• Published: Oct 8, 2008 - Page: 1D - UPDATED: 12:05 a.m.

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Insurance Commissioner Jim Donelon wants to end what he calls “an abusive practice” that forces some consumers to pay thousands in out-of-network costs even though they sought treatment at a hospital that’s part of their health plan.

The problem is that although a hospital may be part of a consumer’s network, the radiologists, anesthesiologists and pathologists at the facility may not have contracts with the consumer’s health insurer, Donelon said. In addition to owing a deductible and co-pay to the hospital, the consumer may get a bill for thousands of dollars from an anesthesiologist he or she has never heard of or for hundreds of dollars for blood work run by a pathologist.

“It is my intent to stop this abuse by the passage of a bill that Sen. (Edwin) Murray introduced for me last session,” Donelon said.

Although that bill failed to gather enough support for passage, Donelon said the bill will be his top priority during the next legislative session.

The new bill would force insurers to cover “reasonably anticipated” ancillary services, such as X-rays, anesthesiology and blood tests, performed when a patient is in the hospital, Donelon said. Insurers are already required to do this for health plan members who have to go to the emergency room, even if the emergency room is in another state.

However, Dr. Vincent Culotta, chairman of the Louisiana State Medical Society’s Council on Legislation, said the situation is complicated.

Most hospitals contract with a single group of anesthesiologists, or radiologists or pathologists, Culotta said. It’s more efficient and allows hospitals to run in a more orderly fashion.

In most hospitals, the patients that cannot pay for care are rotated among different physician practices, Culotta said. But radiologists, anesthesiologists and pathologists have to treat everyone who comes into the hospital regardless of their ability to pay.

And these specialists have to maintain liability insurance because they can still be sued even when providing free care, he said. So radiologists, anesthesiologists and pathologists have to bill the way they do in order to stay in business.

There is a significant cost to providing uncompensated care and that cost has to be made up by everyone who uses the hospital, Culotta said.

“I don’t know that it’s going to change because nobody’s going to want to take a contract that says not only can you not get paid for people that don’t have money, but the people that have money and insurance can’t be forced to pay the full bill,” Culotta said.

Donelon said the physicians’ reasoning is better than no excuse at all, but he in no way agrees with it.

The proposed legislation would make these costs the burden of insurers, which would pressure the insurers to push the hospitals to make the doctors become part of the health networks, Donelon said. There is no motivation to do so now.