医疗账单上，隐藏的收费防不胜防

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

医疗账单上，隐藏的收费防不胜防

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

12月，37岁的彼得·德里耶(Peter Drier)因椎间盘突出接受了三个小时的颈部手术。术前，他签署了一大堆同意书。身为银行的技术经理，德里耶充分研究过自己医保的赔付范围，所以当账单陆续发到时，他早已做好了心理准备——曼哈顿勒诺克斯山医院(Lenox Hill Hospital)的5.6万美元，麻醉师的4300美元，甚至还有骨科医生的13.3万美元，他知道后者只能接受那笔费用的一小部分。

He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.

然而，当他看到一名“外科助理医生”发来的约11.7万美元的账单，他还是傻了眼，记忆中他根本不曾见过这名皇后区的神经外科医生。

“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”

“我以为自己已经充分了解了其中的风险，”家住纽约市的德里耶后来这么说道。“但是我错了，错得离谱——我根本没有选择的余地，也没有讨价还价的权力。”

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.

在全美各地，医生和其他医疗服务提供者常常在手术室和医院病房中互相帮助，协力完成患者的医护工作。但是，一种被部分医疗专家称为“隐蔽性强迫医疗”的做法正日益普遍——无论助理医生还是医疗顾问，甚至连医院的其他员工都开始向患者或其保险公司收取高昂的费用，尽管有时他们的加入并没有什么必要。而患者往往是直到结算账单之时，才发现有一大堆人参与了自己的医护过程，并为此计费。

The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier’s case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion.

当保险公司不断削减众多医疗服务的报销额度时，这种做法显然可以增加医生和其他医护人员的收入。从德里耶的案例可以看出，此类意外费用可能极高，因为其中可能涉及医保网络外的医疗保健提供者，而他们的收费往往高达平常的地方医疗费率的20到40倍，而且报销额度极低，甚至完全不能报销。

“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. This contributes to the nation’s $2.8 trillion in annual health costs.

“这样，通过增加可收费项目，你就绕过了价格管制。”不久前刚离职的前布鲁金斯学会(Brookings Institution)卫生政策专家达沙克·桑加维(Darshak Sanghavi)说。全美的年医疗费用达到2.8万亿美元，其中不乏此类原因的推动。

Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies. Multiple state health insurance commissioners have tried to limit patients’ liability, but lobbying by the health care industry sometimes stymies their efforts.

保险公司表示他们已经对这些激增的意外收费提起诉讼。近年来，在纽约州保险公司监管机构收到的投诉中，意外的网络外收费居于首位。也有多位州医疗保险监察官试图减轻患者负担，但保健行业的游说不时阻挠他们的工作。

“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”

“事态已经演变到了相当糟糕的程度，这样是不对的，”路易斯安那州共和党的保险监察官詹姆斯·J·唐龙(James J. Donelon)说。“但是，每当政策制定者试图解决这个问题，总会捅到经济利益的马蜂窝。”

In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not. Dr. Mu’s office did not respond to requests for comment.

以德里耶为例，他的主刀医生纳撒尼尔·L·廷德尔(Nathaniel L. Tindel)表示愿意接受德里耶的保险公司提出的议价，即约6200美元。(其中德里耶须支付3000美元，才能达到免赔额。)但助理医生哈里森·T· 穆(Harrison T. Mu)不在医保网络之内，而他发出的账单竟达11.7万美元。保险专家称，医生和助理医生有时会分享手术的收益，但廷德尔医生的办公室表示他们与穆之间无此协议。穆的办公室没有回应记者的采访请求。

The phenomenon can take many forms. In some instances, a patient may be lying on a gurney in the emergency room or in a hospital bed, unaware that all of the people in white coats or scrubs who turn up at the bedside will charge for their services. At times, a fully trained physician is called in when a resident or a nurse, who would not charge, would have sufficed. Services that were once included in the daily hospital rate are now often provided by contractors, and even many emergency rooms are staffed by out-of-network physicians who bill separately.

在医院里，这种“隐蔽性强迫医疗”可能以多种不同的形式出现。在某些情况下，可能患者躺在急诊室的轮床上或医院的病床上，浑然不知从他床边晃过的所有穿白大褂或手术衣的人都是要收费的。有时，明明不需额外收费的住院医生或护士就足以应付局面，偏偏要呼叫训练有素的专科医师前来。许多原本应在医院日常收费范围内的服务现在改由承包商提供，甚至许多急诊室都在使用单独收费的网络外医生。

Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.

帕特里夏·考夫曼(Patricia Kaufman)前不久在长岛医院(Long Island hospital)接受了背部手术，此后她的账单中就充斥着此类费用，她的丈夫艾伦(Alan)花了数天时间才将它们拣选整理出来。两名整形外科医生要求的切口缝合费超过了25万美元，而在考夫曼女士此前经历的手术中(她患有慢性神经系统疾病，需要多次手术)，这一工作一向是由住院医生完成的。

In the days after the operation, “a parade of doctors came by saying, ‘How are you,’ and they could be out of network or in network,” Mr. Kaufman said. “And then you get their bills. Who called them? Who are they?”

手术后的那几天，“成群结队的医生——也不知道是网络内的还是网络外的——从你身边走来过去，顺口问候你一句，然后你就会收到他们的账单，”考夫曼先生说。“谁把他们叫来的?他们究竟是些什么人?”

Doctors’ offices often pursue patients for payment. Ms. Kaufman’s insurer paid about $10,000 to the plastic surgeons, who then sent a bill for the remainder. The couple, of Highland Park, N.J., refused to pay.

医生办公室一般都会向患者追讨费用。考夫曼女士的保险公司已经向整形外科医生支付了约1万美元，结果他们又发了一份账单列举了其余的费用。这一次，这对生活在新泽西州海兰帕克市的夫妇表示拒绝支付。

When insurers intervene in a particular case, they say they have limited ability to fight back. Insurance examiners “are not in the room on the day of surgery to see the second surgeon walk into the room or why they were needed,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group. And current laws do not require hospitals that join an insurance network to provide in-network doctors, labs or X-rays, for example.

当保险公司介入特定的案例时，他们往往表示自己有心无力。美国保险业的行业组织——美国医疗保险计划(America’s Health Insurance Plans)的女发言人克莱尔·克鲁辛(Clare Krusing)称，保险核查员“在手术当天并不在场，无法确认是否有第二名外科医生进入手术室以及为何需要额外的医生。”而现行法律也并未要求参加保险网络的医院必须提供网络内的医生、实验室化验或X射线检查等。

So sometimes insurers just pay — to protect their customers, they say — which encourages the practice. When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the full amount.

所以有时候保险公司只好照价付款，以保护他们的客户(起码他们自己是这么说的)，但这无疑又鼓励了这种漫天要价的“隐蔽性强迫医疗”。当德里耶向其保险公司安盛蓝十字蓝盾公司(Anthem Blue Cross Blue Shield)投诉，表示自己不应为网络外的助理外科医生付费时，安盛也认同那确实不是他的责任。于是公司向穆医生开具了一张面额为116862美元的支票，全额支付。

Unexpected Fees

意想不到的费用

When Mr. Drier agreed to surgery in December, he was not in a good position to bargain or shop around. Several weeks earlier, he had woken up to excruciating pain in his upper back and numbness and weakness in two fingers of his left hand, which persisted. A scan showed that one of the disks that normally serve as cushions between vertebrae was herniated and pushing on a nerve. With a busy job and social life, he was living on painkillers.

12月，当德里耶同意手术时，形势可容不得他去讨价还价或者货比三家。早在几周之前，他的背部就已经出现难以忍受的疼痛和麻木，左手还有两个手指持续乏力。扫描显示，那些本应在脊椎之间起缓冲作用的椎间盘之中，有一个椎间盘突出了，并压迫了神经。但由于工作和社交生活过于繁忙，他只能靠止痛药撑着。

The rate of spinal surgery in the United States is about twice that in Europe and Canada, and five times that in Britain, said Dr. Richard A. Deyo of Oregon Health and Science University, who studies international comparisons. Studies are limited but have generally concluded that after two years, patients who have surgery for disk problems do no better than those treated with painkillers and physical therapy — although the pain, which can be debilitating, resolves far more rapidly with surgery.

俄勒冈健康与科学大学(Oregon Health and Science University)的理查德·A·戴约(Richard A. Deyo)在对世界各国的情况进行比较研究后表示，美国的脊柱手术率约为欧洲或加拿大的两倍，约为英国的五倍。尽管相关的研究有限，但一个普遍的结论是：虽然采用手术方式治疗椎间盘问题能使患者更快地摆脱疼痛的侵扰(疼痛可能致使人身体虚弱)，但手术患者在两年后的情况并不比接受止痛剂和物理疗法的患者更好。

The United States has more neurosurgeons per capita than almost any other developed country, and they compete with orthopedists for spinal surgery. At the same time, Medicare and private insurers have reduced payments to surgeons. The average base salary for neurosurgeons decreased to $590,000 in 2014 from $630,000 in 2010, according to Merritt Hawkins, a physician staffing firm.

以人均神经外科医生的数量而言，美国在所有发达国家中位居前列。在脊柱外科中，这些神经外科医生与骨科医生形成了竞争关系。与此同时，联邦医疗保险 (Medicare)和私营保险公司支付给医生的费用却在减少。根据医生人力资源公司梅里特·霍金斯(Merritt Hawkins)的报告，2014年，神经外科医生的平均基本工资已经从2010年的63万美元降至59万美元。

To counter that trend, some spinal surgeons have turned to consultants — including a Long Island company called Business Dynamics RCM and a subsidiary, the Business of Spine — that offer advice on how to increase revenue through “innovative” coding, claim generation and collection services.

针对这一趋势，一些脊柱外科医生转职顾问行业(其中包括长岛的一家名为Business Dynamics RCM的公司及其子公司Business of Spine)，告诉顾客如何“创造性地”通过难懂的行话、无中生有的费用申报和收账服务来增加收入。

Some strategies used by surgeons, including billing large amounts for a second surgeon in the room or declaring an operation an emergency, raise serious questions. The indications for immediate spinal surgery, such as loss of bladder function or rapidly progressive paralysis, are rare. But insurers are more likely to reimburse a hospital or surgeon with whom they do not have a contract if a case is labeled an emergency.

一些外科医生采用的策略，包括为手术室再加一名外科医生而收取巨额费用，或声称某一手术为紧急手术等，引起了严重的问题。紧急脊柱外科手术的适应证，如丧失膀胱功能或快速进行性麻痹等均非常罕见。不过，倘若某一病例被标记为紧急病例，保险公司向未签合同的医院或医生报销医疗费用的机会更大。

Mark Sullivan, 46, of New Jersey, went to an emergency room last year with excruciating lower back pain and leg weakness. He was in the operating room less than 24 hours later. “The surgeon stood at the foot of my bed and said, ‘You need surgery; you won’t walk out of the hospital,’ ” he recalled.

去年，46岁的新泽西州人马克·沙利文(Mark Sullivan)因剧烈腰痛和下肢无力到急诊室就诊。不到24小时，他就被送进了手术室。“当时，”沙利文先生回忆道，“外科医生站在床脚对我说：‘你需要动手术，不然你可能就走不出医院的大门了。’”

Mr. Sullivan’s emergency admission made it easier for an out-of-network surgeon to perform the operation and bill $29,000. The insurer paid $9,500, and Mr. Sullivan paid about $580, as required by his plan. When the doctor’s billing office pursued Mr. Sullivan for the balance of the bill and even threatened to turn his account over to collection, he agreed to file an appeal with his insurer for additional payment, but he refused to pay more himself.

沙利文的急诊入院大大便利了网络外的医生参与他的手术，并为此收费2.9万美元。保险公司支付了其中的9500美元，沙利文也按照其保单的要求支付了约580美元。该医生的医保结算办公室向沙利文追讨手术费余额，甚至威胁采取强制追讨途径，沙利文同意向保险公司申诉要求支付其余的费用，但他自己拒绝再出一分钱。

A Last-Minute Surprise

最后一分钟的“惊喜”

Mr. Drier’s concern about extra charges began even during his preoperative physical. The hospital sent his blood tests to an out-of-network lab and required him to have an echocardiogram (eventually billed for $950), even though he had no cardiac history. (The American Society of Echocardiography discourages such testing for patients with no known heart problems.)

早在德里耶接受术前检查时，他就已经开始对额外收费问题顾虑重重。医院将他的血液化验发送给了一家网络外的实验室，还在他并无心脏病史的情况下要求他接受超声心动图检查(最后收费950美元)。(美国超声心动图学会[American Society of Echocardiography]不鼓励对无已知心脏问题的患者进行此类检查。)

His worries escalated as he lay prepped for the operating room on the morning of his surgery. A technician from a company called Intraoperative Monitoring Service L.L.C. asked him to sign a financial consent form, noting that the company did not accept Blue Cross Blue Shield plans, so he would be required to pay the bill himself. The monitoring had been ordered by his surgeon and is considered essential for the type of neurosurgery he was having, to make sure delicate nerves are not damaged as they are manipulated.

手术当天的上午，当他躺在手术室里，准备接受手术时，他的忧虑进一步加剧了。一名自称来自手术监测服务有限公司(Intraoperative Monitoring Service L.L.C.)的技术人员要求他签署一份财务同意书，声明由于该公司不接受蓝十字蓝盾公司的医保方案，德里耶将需要自己支付账单。他的外科医生为他订购了该公司的监护服务，称该监护可确保精细的神经不会在手术操作中受到损害，因此对于他要接受的这类神经外科手术必不可少。

“I demanded to know the price, and when he said he didn’t know, I made him call,” Mr. Drier recalled. When the technician said it would be $500 plus an hourly rate, Mr. Drier negotiated it down to $300.

“我要求先知道价钱，他说他也不知道，于是我就让他打电话去问，”德里耶回忆说。然后技术人员告诉他：“起步价”为500美元，其余部分按小时计费，经过一番协商，双方同意将基础费用砍到300美元。

In the operating room, he underwent a procedure called spinal fusion, in which the surgeons removed two herniated disks that were impinging on nerves, and inserted some bone graft as well as plates and screws to stabilize the spine. On his hospital bill, Mr. Drier noted charges for three implants, a total of about $10,400, as well as for two surgical screws billed at $2,470 and $3,990 — expensive for hardware, he thought, but his insurer paid the full amount.

在手术室中，德里耶接受了脊柱融合术。外科医生切除了压迫神经的两个突出的椎间盘，然后插入骨移植物、钢板和螺钉来固定脊柱。在医院发来的账单中，德里耶发现三个植入物收费约10400美元，两枚手术螺钉则分别要价2470美元和3990美元——这可真是天价螺钉，他想，但他的保险公司支付了全部费用。

The biggest surprise was the bill from Dr. Mu, the assistant surgeon. Fusions generally require a second trained pair of hands, but those can be provided by a resident or a neurosurgical nurse or physician assistant employed by the hospital, for whom there is no additional charge. The operative record for Mr. Drier’s surgery states that no qualified resident was available.

而最大的“惊喜”莫过于助理外科医生穆发来的账单。通常，融合术确实需要有一个受过专业训练的人来配合主刀医生，但这一任务完全可以由住院医生、神经外科护士或助理医生承担，他们都是无需额外收费的。在德里耶的手术记录上是这样写的：没有符合资格的住院医生可用。

Dr. Mu is the chief of neurosurgery at Jamaica Hospital Medical Center in Queens, though he sometimes operates at other hospitals. According to a database that tracks hospital admissions in New York State, most operations he performs at Jamaica involve emergency surgery on Medicaid patients, often victims of trauma — a challenging but probably not very lucrative practice.

穆是皇后区牙买加医院医学中心(Jamaica Hospital Medical Center)的神经外科主任，但他时不时也会到其他医院做手术。据跟踪纽约州医院接诊情况的数据库显示，他在牙买加医院进行的大部分手术都是联邦医疗补助( Medicaid)计划覆盖的紧急手术。这些患者往往是外伤受害者，这一类手术的风险和难度都很大，收入却不高，做起来委实不够合算。

One insurer, Aetna, is in court with Dr. Mu’s private-practice group, NeuroAxis Neurosurgical Associates of Kew Gardens, Queens. NeuroAxis sued to recover higher payments for its out-of-network assistant surgeons; Aetna says the practice’s fees for those surgeons are excessive. J. Edward Neugebauer, chief litigation officer at Aetna, said the company had also sued an in-network neurosurgeon on Long Island who always called in an out-of-network partner to assist, resulting in huge charges. The surgeons shared a business address.

目前，安泰保险公司(Aetna)正与穆的私人诊所组织——皇后区邱园神经轴神经外科协会(NeuroAxis Neurosurgical Associates of Kew Gardens, Queens)对簿公堂。“神经轴”提起诉讼，要求追讨其网络外助理医生的高额费用，而安泰则认为，这些诊所为上述医生收费过高。安泰的首席诉讼官J·爱德华·诺伊格鲍尔(J. Edward Neugebauer)表示，该公司还起诉了长岛的一名网络内神经外科医生，因为他总是要求网络外的合作伙伴协助，造成巨额的医疗费用。这些外科医生甚至还共用同一个办公地址。

Surgeons from other specialties also team up: After Gunther Steinberg of Portola Valley, Calif., had a needle biopsy of an eye lesion in 2010, he discovered that his insurer had paid about $10,000 to the eye surgeon who performed the outpatient procedure and $10,700 to a second ophthalmologist in the room.

在其他医学专科的外科医生中，也存在类似的组队现象。2010年，家住加州波托拉谷的冈瑟·斯坦伯格(Gunther Steinberg)接受了眼部病灶的穿刺活检，其后，他发现自己的保险公司除了向门诊的眼科医生支付了约1万美元之外，还向手术室里的另一名眼科医生支付了10700美元。

“The idea of having an assistant in the O.R. has become an opportunity to make up for surgical fees that have been slashed,” said Dr. Abeel A. Mangi, a professor of cardiac surgery at Yale, who said the practice had become commonplace. “There’s now a whole cadre of people out there who do not have meaningful appointments as attending surgeons, so they do assistant work.”

“在手术室里使用助理医生已经成为捞回被削减的手术费的一个大好机会，”耶鲁大学的教授阿比尔·A·曼吉(Abeel A. Mangi)博士说，这种做法已经司空见惯。“现在有一大堆医生没有出诊外科医生这样的正经头衔，于是他们就做助理工作。”

In Mr. Drier’s case, each surgeon billed for each step of the procedure. Dr. Tindel billed $74,000 for removing two disks and an additional $50,000 for placing the hardware that stabilized Mr. Drier’s spine. Dr. Mu billed $67,000 and $50,000 for those tasks.

在德里耶的案例中，每位医生都针对手术中的各个步骤事无巨细地收取了费用。廷德尔医生切除了两个椎间盘，收费7.4万美元;安置螺钉之类的部件固定德里耶的脊柱，又是5万美元。穆则为上述程序分别要价6.7万美元和5万美元。

If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee. With current Medicare rates, that would have been about $800, less than 1 percent of what Dr. Mu was paid.

假若手术的对象是一名联邦医保患者，那助理医生的收费将不得超过主刀医生的16%。按照目前联邦医保的保险费率，不过800美元上下，还不到穆的收费的1%。

Visitors Who Bill

开账单的外来者

Unexpected fees are routinely generated outside the operating room as well. On the wards, a dermatologist may be called in to examine a rash and perform an expensive biopsy. The person in scrubs who walks a patient to a bathroom for the first time after hip surgery may turn out to be a physical therapist billing $400.

意外费用也常常产生在手术室之外。在病房，一个皮疹可能就会招来皮肤科医生，又检查又进行昂贵的活检。髋关节手术后，那个身穿手术服、护送患者初次去洗手间的家伙搞不好其实是个物理治疗师，给你留下400美元账单。

Mr. Sullivan, who had the emergency back surgery, discovered charges from more than 10 providers in the 48 hours after his operation. (The surgery involved simply trimming a herniated disk in his lower back.) He wrote to various doctors to dispute bills, saying, “I was admitted to Overlook Hospital from Nov. 26-27, 2013, and I have received numerous invoices for procedures that were never done, by physicians that never treated me.”

沙利文先生发现，在他接受紧急背部手术后的48小时内，就有10多个医疗保健提供者要求收取各种费用。(该手术仅涉及对其腰部的椎间盘突出进行细微的修整。)他给许多不同的医生们写信，对这些账单提出了异议：“2013年11月26日至27日期间我在远景医院(Overlook Hospital)就诊，但是，一大堆从来没有治疗过我的医生却以各种我从未接受过的医护程序为名，给我开了无数账单。”

He was puzzled by $679 in occupational therapy charges involving the delivery of a device to help him put on his socks, which he never used. He was irate about charges from a group of hospital-based primary care physicians from Inpatient Medical Associates, who visited him briefly once a day and billed close to $1,000 in out-of-network costs.

其中一项金额为679美元的职业疗法(occupational therapy)账单显示，他使用了一种可以协助自己穿袜子的设备，这让他迷惑不解，因为他从未用过这玩意儿。等他看到一帮住院医疗协会 (Inpatient Medical Associates)的驻院初级保健医生发来的账单时，他已经极度愤怒了——那些人每天只在他面前转一圈，却要按照网络外医生的收费标准收取近1000 美元的费用。

Healthy surgical patients typically do not need a general doctor; an anesthesiologist clears them for surgery. Mr. Sullivan noted that if he had needed an internist, he would have called his own, who is in his insurance network and whose office is just down the block.

健康的手术患者通常并不需要全科医生;麻醉师可以确定他们能否接受手术。沙利文先生也表示，如果他需要内科医生，他会打电话给自己的医生的，那位医生不但在保险网络之内，而且其办公室就在这个街区不远处。

Dr. Mangi, the Yale cardiac surgeon, said hospitals often encouraged extra visits for both billing and legal reasons. He said he was required to request a physical therapy consult before each discharge, for example, even if he felt there was no need.

耶鲁大学的心脏外科医生曼吉博士表示，出于收费以及法律方面的原因，医院往往会鼓励外来的医护人员参与医护过程。例如，每次有患者要出院时，医院总是要求他提请为患者进行物理治疗会诊，即使有时候他觉得完全没那个必要。

“You can cut fees, but institutions find ways” to make the money back, he said. “There’s been a mushrooming industry of mandatory consultants for services that neither doctors nor patients want.”

“你可以削减费用，但医疗机构总会想方设法”把钱赚回来，他说。“强制性服务咨询行业像雨后的蘑菇一样冒了出来，但无论是医生也好，患者也好，其实都不想要这些东西。”

A Possible Remedy

一种可能的解决之道

For months, Mr. Drier stewed over what to do with the $117,000 check Anthem Blue Cross had sent him to pass on to Dr. Mu, refusing to sign over a payment he considered “outrageous and immoral.” He worried that such payments could drive up premiums at his employer.

几个月来，德里耶辗转反侧，不知该拿安盛蓝十字要他转交给穆的那11.7万美元支票怎么办。他不愿意签付这笔在他看来“高得离谱，简直不道德”的款项。他担心这样的费用可能会抬高其雇主的保险费。

In the past few years, some insurers have filed lawsuits and sought injunctions to prevent providers from going after their clients for payment of unexpected medical bills. Dr. Scott Breidbart, chief medical officer at Empire Blue Cross Blue Shield, part of the same parent company that covers Mr. Drier, said that it had not taken that route, but that in some situations it had refused to do further business with in-network surgeons who repeatedly called in out-of-network assistants.

在过去的几年中，一些保险公司已经提起诉讼，要求颁布禁令，防止医疗保健提供者向他们的客户追讨意外的医疗帐单。帝国蓝十字蓝盾公司(Empire Blue Cross Blue Shield，从属于为德里耶承保的母公司)的首席医疗官斯科特·布雷德巴特(Scott Breidbart)博士称，目前他们尚未采取这条途径，但在某些情况下，该公司将拒绝与一再要求网络外助理医生参与医护服务的网络内外科医生继续合作。

A New York State law that will take effect in March — one of a few nationally — will offer some protection against many surprise charges and require more advance disclosure from doctors and hospitals on whether their services are covered by insurance. It states, for example, that patients are not responsible for unforeseen out-of-network charges beyond what they would have paid in-network. It directs insurers and hospitals to negotiate any further payment or enter mediation.

纽约州的相关法律将在3月生效。在全美范围内，此类法律尚属少数，它将为患者及其保险公司提供一定程度的保护，帮助他们应对多种意外收费，并将要求医生和医院提前披露他们的服务是否在投保范围。例如，它指出，患者将无需为超出网络内医疗费用限度的不可预见的网络外收费负责。它还将指导保险公司和医院如何就额外的费用进行协商或进入调解程序。

In many other countries, such as Australia — where, as in the United States, people often rely on private insurance — it is seen as a patient’s right to be informed of out-of-pocket costs before hospitalization, said Mark Hall, a law professor at Wake Forest University.

维克森林大学(Wake Forest University)的法学教授马克·霍尔(Mark Hall)认为，在美国、澳大利亚以及其他许多国家中，人们往往依赖于私人保险，因此在住院前了解自己的实付费用是患者的正当权益。