A Patient Advocate's View

Gottfried still solid on Single-Payer

Let New York Health help pay the bills

By Richard N. Gottfried

Published 11:31 p.m., Sunday, April 1, 2012


You buy a health insurance policy that covers care by “in-network” doctors and other providers, but also promises that if you go to an “out of network” provider, it will pay based on “usual and customary charges.” Your family doctor refers you to an out-of-network specialist, and it turns out the insurance company offers to pay about half the bill you get.

A few years ago, then-Attorney General Andrew Cuomo and a group of physicians brought a massive lawsuit against the top insurance companies. The charge was that those insurers were promising to pay based on “usual and customary” rates for out-of-network services, but those rates were bogus — and outrageously low.

The insurance companies agreed to settle the case. They agreed that the attorney general would set up an independent nonprofit organization, called Fair Health, to publish legitimate data the insurance companies would use for determining “usual and customary” charges.

Now, insurers are getting around the settlement by no longer promising to pay based on usual and customary; they will pay whatever they choose to pay.

So I have introduced a bill in the Assembly, carried in the Senate by Senate Health Committee chairman Kemp Hannon. It says that your health insurer company must disclose how it calculates out-of-network payments, and state them as a percentage of the Fair Health usual-and-customary rate. And it says the state Department of Financial Services — the new name of what used to be the Insurance Department — may not approve an out-of-network insurance policy unless it actually provides “significant coverage” of the Fair Health usual-and-customary rate.

In other words, insurers have to be open with their customers, and they can’t claim a policy covers out-of-network services if it doesn’t really pay reasonable amounts for them.

A Times Union Commentary page article last week, by an executive of the for-profit insurance company Empire Blue Cross-Blue Shield, says that our bill would “mandate a minimum reimbursement [to out-of-network providers] based on the Fair Health database.”

The bill does not do that. It would require disclosure and stop insurance companies from selling products that don’t really provide what consumers expect.

The Fair Health court settlement was hailed as a landmark. But the health insurance companies quickly found a way around it. If our bill becomes law, they may find a way around that, too. The problem is, whatever reforms we enact, our health coverage still relies on insurance companies.

Instead, New York should establish a universal publicly funded single-payer system, funded by broad-based revenue based on ability to pay. I sponsor an Assembly bill, carried in the Senate by Tom Duane, to set up such a system, called “New York Health.”

You and your doctor would work on keeping you healthy, and New York Health would pay the bill.

Richard N. Gottfried of Manhattan is chairman of the state Assembly Committee on Health.

Read more:

April 25, 2012 - Posted by | Uncategorized

No comments yet.

Leave a Reply

Please log in using one of these methods to post your comment: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: