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Congress Comes Together On Surprise Medical Billing

posted by AHIP

on May 30, 2019

Every year, Americans make about 145 million visits to emergency rooms in the United States, and more than one-third of all patients are referred to a specialist. These visits come with health-related worries, but for too many Americans, they also come with an unexpected surprise – a medical bill with unexpected charges.

Patients should be protected from surprise medical bills – but this is a growing problem that continues to hurt patients and their families.

Thankfully, there is recent bipartisan momentum on Capitol Hill to come together to address surprise medical bills. The No Surprises Act was recently introduced in the House Energy and Commerce Committee by Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR). This bill would ensure patients are protected and that doctors are paid appropriately. It would also prohibit arbitration from being used to settle billing disputes, which only incentivizes doctors and hospitals to set higher prices, adds more government bureaucracy and red tape, and increases costs to taxpayers.

Why do surprise medical bills happen?

Health insurance providers work with hospitals and doctors to set rates for the cost of care and cover much of the cost for patients who receive in-network services. However, too often patients are treated by an out-of-network doctor without being told about it. Worse, because out-of-network doctors don’t have a set contract with health insurance providers, they can charge whatever they want—giving them an incentive to stay out-of-network and charge patients more for treating them.

It is a complicated problem that varies widely by medical specialty. A recent survey by the Health Care Cost Institute explored the prevalence of out-of-network billing by medical specialty and found that hospital-based physicians send a disproportionate number of surprise bills, and we know these providers charge well in excess of their peers and are most likely to remain out-of-network. For example, anesthesiologists alone accounted for 16.5% of surprise bills.

While some states have taken action to address this issue, policymakers need to do more to protect patients, particularly the more than 100 million Americans who receive employer-provided coverage that is self-funded by their employer. These plans are not regulated at the state level – so Congress needs to take action at the federal level to protect all Americans.

AHIP recently published an issue brief outlining recommendations for reforms to protect patients from surprise billing. As policymakers are considering how to tackle this issue, they should consider reforms that:

  • Prohibit surprise medical bills: Doctors shouldn’t be allowed to bill patients for costs not covered by their health insurance provider.
  • Protect patients when they need treatment: Patients need to be protected when they are most vulnerable. That includes situations when they need emergency medical treatment, ambulance services, or an out-of-network physician working at an in-network hospital.
  • Establish an appropriate, market-based reimbursement standard: Health insurance providers and doctors should work together to build networks that deliver high quality care and value.
  • Keep patients informed: Patients have a right to know about the costs of their treatment and options, and they should receive complete information about whether a doctor or health care facility does not participate in their coverage.

“Every American deserves affordable, high-quality coverage and care, as well as control over their own health care choices,” said a group of leading organizations representing consumers, businesses, and health insurance providers earlier this year. While more work needs to be done, it is encouraging to see policymakers willing to work together to protect patients from the financial pain of surprise medical bills.