As policymakers prepare to take corrective action, “providers must have a seat at the table to ensure the policies that are enacted are sensible,” she maintains.
WHY SURPRISE MEDICAL BILLING IS SUCH A PROBLEM
In many states, providers that do not participate in a patient’s insurance network can bill for the difference between the charged amount and a health plan’s allowable amount. Surprise bills may also reflect steeper patient cost-sharing for seeing an out-of-network provider.
In some cases, surprise bills can exceed more than $100,000. For example, a teacher received a bill for nearly $110,000 following a heart attack. Another patient received a bill for nearly $50,000 for a cat bite—with $46,422 of that total for one preventative medication.
Surprise medical billing is not a new issue. In fact, the rate of surprise bills has slipped over time as the share of physicians employed by hospitals has risen. So why has it snowballed as a policy issue?
The growth of narrow networks, which exclude certain higher-priced providers in the marketplace, is partly to blame. Surprise medical bills can also be a particular problem for patients living in rural areas, where competition is limited. That allows specialists to resist insurers’ demands. What’s more, heightened media coverage has drawn attention to the problem.
“A lot of it is intertwined with the ongoing debate around costs, so when someone sees a bill with a $50 charge for aspirin, that gets drawn into the discussion too,” Krilow points out.
WHAT'S THE FIX FOR SURPRISE BILLING?
Several states, including California, Florida, New York and Texas, have taken steps to rein in unwieldy billing. However, such measures do not protect consumers covered through self-insured plans, and that includes a majority of people who have employer-sponsored coverage. This loophole has fueled demand for a broader, federal solution.
Legislative remedies are under consideration on Capitol Hill to end surprise medical billing. Key differences among the bills include:
- How out-of-network emergency care at in-network facilities is treated—for example, limiting patients’ financial responsibility to the in-network amount or completely banning balanced billing in this circumstance.
- How payment rate disputes are handled: through arbitration, network matching or use of a regional benchmark rate.
- Which transparency requirements are included to ensure that patients are properly informed about out-of-network care.
Right now, the two main bills being considered—one in the Senate and one in the House of Representatives—are similar in how they set benchmark rates for out-of-network services.
Krilow says a key difference, and one that’s critical to hospital providers, is that the House bill currently allows for an arbitration process to help settle disputes between providers and payers, whereas the Senate bill does not.