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Last year in Massachusetts, after finding lumps in her breast, Jessica Chen went to Lowell General Hospital-Saints Campus, part of Tufts Medicine, for a mammogram and sonogram. Before the screenings, she asked the hospital for the estimated patient responsibility for the bill using her insurance, Tufts Health Plan. Her portion, she was told, would be $359 — and she paid it. She was more than a little surprised weeks later to receive a bill asking her to pay an additional $1,677.51. “I was already trying to stomach $359, and this was many times higher,” Chen, a physician assistant, told me. The No Surprises Act, which took effect in 2022, was rightly heralded as a landmark piece of legislation, which “protects people covered under group and individual health plans from receiving surprise medical bills,” according to the Centers for Medicare & Medicaid Services. And yet bills that take patients like Chen by surprise just keep coming. With the help of her software-wise boyfriend, she found the complicated “machine-readable” master price list that hospitals are required to post online and looked up the negotiated rate between Lowell General and her insurer. It was $302.56 — less than she had paid out-of-pocket. CMS is charged with enforcing the law, so Chen sent a complaint about the surprising bill to the agency. She received a terse email in return: “We have reviewed your complaint and have determined that the rights and protections of the No Surprises Act do not apply.” When I asked the health system to explain how such a surprising off-estimate bill could be generated, Tufts Medicine spokesperson Jeremy Lechan responded by email: “Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause.” Here’s the problem: While the No Surprises Act has been a phenomenal success in taking on some unfair practices in the wild West of medical billing, it was hardly a panacea. In fact, the measure protected patients primarily from only one particularly egregious type of surprise bill that had become increasingly common before the law’s enactment: When patients unknowingly got out-of-network care at an in-network facility, or when they had no choice but to get out-of-network care in an emergency. In either case, before President Donald Trump signed the law late in his first term, patients could be hit with tens or hundreds of thousands of dollars in out-of-network bills that their insurance wouldn’t pay. The No Surprises Act also provided some protection from above-estimate bills, but at the moment, the protection is only for uninsured and self-pay patients, so it wouldn’t apply in Chen’s case since she was using health insurance. But patients who do qualify generally are entitled to an up-front, good-faith estimate for treatment they schedule at least three business days in advance or if they request one. Patients can dispute a bill if it is more than $400 over the estimate. (The No Surprises Act also required what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not been implemented, since, nearly five years later, the government still has not issued rules about exactly what form it should take.) So, surprising medical bills — bills that the patient could not have anticipated and never consented to — are still stunning countless Americans. Jessica Robbins, who works in product development in Chicago, was certainly surprised when, out of the blue, she was recently billed $3,300 by Endeavor Health for a breast MRI she had received two years earlier, with prior authorization from her then-insurer, Blue Cross and Blue Shield of Illinois. In trying to resolve the problem, she found herself caught in a Kafkaesque circle involving dozens of calls and emails. The clinic where she had the procedure no longer existed, having been bought by Endeavor. And she no longer had Blue Cross. “We are actively working with the patient and their insurer to resolve this matter,” Endeavor spokesperson Allie Burke said in an emailed response to my questions. Mary Ann Bonita of Fresno, California, was starting school this year to become a nursing assistant when, on a Friday, she received a positive skin test for tuberculosis. Her school’s administration said she couldn’t return to class until she had a negative chest X-ray. When her doctor from Kaiser Permanente didn’t answer requests to order the test for several days, Bonita went to an emergency room and paid $595 up front for the X-ray, which showed no TB. So she and her husband were surprised to receive another bill, for $1,039, a month later, “with no explanation of what it was for,” said Joel Pickford, Bonita’s husband. In the cases above, each patient questioned an expensive, unexpected medical charge that came as a shock — only to find that the No Surprises Act didn’t apply. “There are many billing problems out there that are surprising but are not technically surprise bills,” Zack Cooper, an associate professor of economics at Yale University, told me. The No Surprises Act fixed a specific kind of charge, he said, “and that’s great. But, of course, we need to address others.” Cooper’s research has found that before the No Surprises Act was passed, more than 25% of emergency room visits yielded a surprise out-of-network bill. CMS’ official No Surprises Help Desk has received tens of thousands of complaints, which it investigates, said Catherine Howden, a CMS spokesperson. “While some billing practices, such as delayed bills, are not currently regulated” by the No Surprises Act, Howden said, complaint trends nonetheless help “inform potential areas for future improvements.” And they are needed. Michelle Rodio, a teacher in Lakewood, Ohio, had a lingering cough weeks after a bout of pneumonia that required treatment with a course of antibiotics. She went to Cleveland Clinic’s Lakewood Family Health Center for an examination. Her X-ray was fine. As was her nasal swab — except for the stunning $2,700 bill it
Ahead of Intelligent Health (13-14 September 2023, Basel, Switzerland), we asked Yurii Kryvoborodov, Head of AI & Data Consulting, Unicsoft, his thoughts on the future of AI in healthcare. Do you think the increased usage of Generative AI and LLMs will have a dramatic impact on the healthcare industry and, if so, how? Generative AI is just a part of the disruptive impact of all AI tech on the healthcare industry. It allows to dramatically reduce time efforts, costs and chances of mistakes. Generative AI and LLMs are applied to automating clinical documentation, drug discovery, tailoring of treatment plans to individual patients, real-time clinical decision support and health monitoring, extracting valuable insights from unstructured clinical records, streamlining administrative tasks like billing and claims processing, providing instant access to comprehensive medical knowledge. And this list continues.
We sat with Benjamin von Deschwanden, Co-Founder and CPO at Acodis AG, to ask him his thoughts on the future of AI in healthcare. Do you think the increased usage of Generative AI and LLMs will have a dramatic impact on the healthcare industry and, if so, how? I think that the strength of Generative AI lies in making huge amounts of information accessible without needing to manually sift through the source material. Being able to quickly answer any questions is going to be transformative for everyone working with increasingly bigger data sets.The challenge will be to ensure that the information we get by means of Generative AI is correct and complete – especially in healthcare – as the consequences of wrong data can be fatal. We at Acodis are actively working on practical applications of Generative AI inside our Intelligent Document Processing (IDP) Platform for Life Science and Pharma clients to drive efficiency and accelerate time to market, whilst controlling the risks.
Intelligent Health 2024 returns to Basel, Switzerland on 11th–12th September. We’ve got prominent speakers. An extensive programme. Groundbreaking advancements in #HealthTech. And much, much more. Our incredible 2024 programme will dive deeper than ever before. From sharing the latest innovation insights to exploring use cases of AI application in clinical settings from around the world. All through our industry-renowned talks, limitless networking opportunities, and much-loved, hands-on workshops. Read on to discover what themes await at the world’s largest AI and healthcare summit.
We sat down with Margrietha H. (Greet) Vink, Erasmus MC’s Director of Research Development Office and Smart Health Tech Center, to ask her for her thoughts on the future of AI in healthcare. Do you think the increased usage of Generative AI and LLMs will have a dramatic impact on the healthcare industry and, if so, how? The integration of Generative AI and LLMs into the healthcare industry holds the potential to revolutionise various aspects of patient care, from diagnostics and treatment to administrative tasks and drug development. However, this transformation will require careful consideration of ethical, legal, and practical challenges to ensure that the benefits are realised in a responsible and equitable manner.
