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AHIP Testifies At Congressional Hearing On Surprise Medical Bills

posted by AHIP

on May 21, 2019

On May 21, 2019, the House Ways and Means Committee held a hearing on surprise medical billing. The panel of witnesses included Jeanette Thornton, AHIP’s Senior Vice President for Product, Employer, and Commercial Policy.

Surprise medical bills occur when patients are treated by out-of-network providers under circumstances where consumers cannot reasonably plan for or avoid treatment from these providers. For example, they can occur following an emergency trip to the hospital, or when an ancillary out-of-network provider cares for a patient during a planned procedure at an in-network facility.

When patients have health care coverage and get care from doctors in their plan’s network, the health insurance provider typically covers costs beyond the copayment, coinsurance, or deductible required under their health plan. However, when patients receive care from out-of-network providers—either voluntarily or involuntarily—the provider often will send patients a bill for charges for which they are responsible. Under current law and practice, most states allow a doctor to bill a patient for any balance that may be outstanding after the health insurance provider pays the costs for which it is responsible.

Patients often don’t realize and have no way of knowing that many physicians are independent contractors who work at the hospital, but not for the hospital, and who independently choose whether or not to join a health plan network. That means that hospitals can have “in network” status, but the doctors delivering care to patients at that hospital might not. This is the type of scenario that leads to surprise medical bills and creates tremendous financial burdens for patients and their families.

Our written testimony outlines four recommendations for federal legislation to protect patients from surprise medical bills:

  • First, balance billing should be banned in situations where patients are involuntarily treated by an out-of-network provider. This includes: (a) emergency health care services provided at any hospital; (b) ambulatory transportation to any health care facility in an emergency; and (c) any health care services or treatment performed at an in-network facility by an out-of-network provider not selected by the patient.
  • Second, health insurance providers should be required to reimburse out-of-network providers an appropriate and reasonable amount in the above scenarios.
  • Third, states should be required to establish an independent dispute resolution process that works in tandem with an established payment benchmark.
  • Fourth, hospitals or other health care providers should be required to furnish advanced notice to patients of the network status of treating providers.