The Louisiana insurance commissioner, hospitals and physicians appear headed for a confrontation during the next legislative session over the billing practices of so-called RAP doctors, or radiologists, anesthesiologists and pathologists.
"You go into Our Lady of the Lake to have your baby with the expectation that you have full coverage subject to your deductible and co-pay," Insurance Commissioner Jim Donelon said. "You have your baby, you go home, you pay your deductible, you pay your co-pay and then out of left field comes a bill for thousands of dollars from an anesthesiologist you've never heard of, and one for hundreds more from a pathologist you never heard of."
Donelon said his top priority for the next legislative session is to get a law passed making insurers responsible for "reasonably anticipated" ancillary services, such as X-rays, anesthesiology and blood tests, performed when a patient is in the hospital.
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, Donelon said. He expects the insurance industry to support the proposed legislation.
However, Dr. Vincent Culotta, chair of the Louisiana State Medical Society's Council on Legislation, said it will be difficult to change the current setup.
Most hospitals contract with a single group of anesthesiologists, or radiologists or pathologists, Culotta said. This gives hospitals to run more efficiently and eliminates the administrative headaches that would result from using three or four groups; for example, no one has to keep track of which doctor prefers to use Group A or D.
The drawback to this approach is that radiologists, anesthesiologists and pathologists have to treat everyone who comes into the hospital regardless of their ability to pay, Culotta said. The RAP doctors cannot evenly distribute the nonpaying patients among their peers, the way that other specialists in hospitals can.
No one is going to want a contract that requires them to treat patients who can't pay and forbids them from billing the full amount for services to people who have insurance and money, Culotta said.
"There is a significant cost to providing care that is uncompensated and that has to be made up by all of us who also use the hospital. If it's me going to the hospital, I have to pay the difference if my insurance doesn't cover it," Culotta said. "But it's to keep a good anesthesiologist there for when I need it, my wife needs it, my kids need it. It's to keep a good pathologist there if my wife needs to know if her breast cancer is in situ or invasive. It's to keep a good radiologist there to read the mammograms that my daughters have, to say that the mammograms are normal, that you don't have breast cancer like your mom might have"
Radiologists, anesthesiologists and pathologists don't like the situation, but they have to bill the way they do to stay in business, Culotta said.
Meanwhile, the RAP doctors have to maintain liability insurance because they can still be sued by the patients who receive free care, Culotta said. Radiologists, anesthesiologists and pathologists have to charge everyone the same rate in order to stay in business.
Donelon disagrees with that explanation.
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. The physicians are "fat and happy" with the current loophole and have no motivation to change without a new law.
Gil Dupré, chief executive officer of the Louisiana Association of Health Plans, said the best solution would be for insurers, radiologists, anesthesiologists, pathologists, Emergency Room doctors and other specialists to agree on a reasonable reimbursement rate under which the doctors could be considered part of the health networks.
Most of these specialists already contract with one or more health plans, Dupré said.
Dupré said Donelon failed to get a similar bill passed during the last legislative session because failed to draw the support needed.
"Nobody's really been able to come up with the perfect resolution to this," Dupré said, "something that's going to protect the consumer, not going to cost all the health plans a great deal more and is going to satisfy the hospitals and physicians that are involved."
It may be impossible to do all those things, he added. But passing a law that makes insurers cover everything without contracts, and passing along the additional costs to consumers and employers sends the wrong message.
Still, Dupré expects the legislature will address the issue, although no one knows what the solution will be.
John Matessino, president and chief executive officer of the Louisiana Hospital Association, said his members cannot control which physicians sign contracts with health. The hospitals don't get involved in those negotiations, he said.
The LHA believes hospitals and health plans should do a better job of letting consumers know which physicians are part of each health network, Matessino said. But there is no conspiracy among hospitals and doctors to inflate costs to consumers.
The opposite is true, Matessino said. Hospitals don't profit from RAP doctor fees.
Matessino said a legislative mandate cutting those specialists' pay could also make it even harder for rural hospitals to attract those physicians.
Culotta said the situation shows how problematic the business model is for RAP physicians.
He compared it to a federal law saying no one in America should go hungry. Under such a law, anyone could walk into a burger joint, demand to be fed, and the restaurant would have to do so.
How many restaurants could stay in business under those conditions? Culotta asked.