The Word For Today Is SURPRISE

Surprise, Americans really do care about health care.  Surprise, repealing the Patient Protection and Affordable Care Act (Obamacare) is no longer good enough, especially when you don’t have a replacement plan.  And Surprise, there are a whole lot of Republican Senators (22) up for reelection in 2020.  There is a way, a bipartisan way, to address all of these issues.  Today we are going to discuss Surprise Billings.

According to the Kaiser Family Foundation:

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.  These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others.  In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network.1    In these non-emergency situations, too, the in-network provider or facility generally arranges for the other treating providers, not the patient.

This is actually a real issue.  Back in 2016, before my little health adventure, I spent several hours trying to verify that every doctor I was about to encounter was in my health insurance network.  I couldn’t do it.  I called both the insurer (Anthem) and the hospital (University Hospital).  I was completely at their mercy.  Luckily, everyone involved was in network.

Emergency care is even more of a crap shoot.  The patient normally has no choice where care is provided nor which doctors are seen.  20% of hospital admissions in 2014 that originated in the emergency room resulted in surprise billings. (Source – Health Affairs).  You may have the ambulance take you to a hospital in your network only to learn, after the fact, that the Emergency Room physician isn’t in your or any network.

There are several bills under consideration in Congress.  Most are bipartisan.  The Trump administration has been supportive.  With this opening, the stakeholders are starting to get more vocal and present possible solutions.   One coalition includes the National Association of Health Underwriters, the National Retail Federation, American’s Physician Groups, America’s Health Insurance Plans, American Benefits Council, Blue Cross Blue Shield Association, ERISA Industry Committee, and the HR Policy Association.  This group understands the nuts and bolts of medical billing and how Surprise Billing directly impacts clients, employees, and average Americans.  It is reasonable to expect that more consumer, business, and labor groups will sign on as action becomes more likely.

The group is organizing around the following principals:

  • Banning balance billing 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.
  • Requiring health insurance providers to reimburse non-participating doctors or clinicians based on a federal standard in the above scenarios. All health plans should be required to reimburse a non-contracted hospital or health care provider in the above scenarios an amount equal to the negotiated rate for the same service under the patient’s health plan contract. If no such rate is ascertainable, then the plan should be obligated to pay the amount required for Medicare Parts A or B or a median contracted rate. These requirements should be applied to all ERISA self-funded health plans, and non-ERISA and insured plans, with the option for states to establish similar standards, so long as the state methodology would not increase patient cost-sharing or premiums.
  • Mandating hospitals and providers disclose the network status for attending physicians and clinicians prior to patients receiving care. For non-emergency situations, hospitals should be required to notify patients at their first point of contact, including by a provider on a patient’s behalf (e.g., scheduling surgeon), that some providers assigned to them may be out-of-network and inform them of their right to select in-network providers or decline care. This notice should be for informational purposes only and not constitute a waiver of patient rights, nor should it act as a statement of consent by the patient to pay for services provided.

This is a great first step.  There is a real possibility that Congress will pass legislation this term and that the president will sign it.  Good news out of Washington – Surprise.


Picture – Dr Thunder Monk Courtesy of Joan Naro – David L Cunix

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5 Responses to The Word For Today Is SURPRISE

  1. Sandy W. says:

    Thank you for this post, Dave.
    It’s great to have some good news on this topic!

  2. […] to needed health care!  Why?  Insurance companies and Congress are trying to solve the Surprise Medical Billing problem by denying fair payment to doctors.  The safety net could be “Shredded”.  The […]

  3. […] Those three points are directly taken from the current Surprise Billing legislation Ohio S B 198.  Until this loophole is removed, Ohioans will still be victimized by Surprise Billing. […]

  4. […] of those issues is Surprise Billing.  On May 20th the Ohio House unanimously passed H.B. 388, the legislation specifically designed to […]

  5. […] Pretty darn good.  The key element is that the patient is no longer a direct victim of Surprise Billing.  The insurance companies will deal with the non-network providers and hedge funds.  Protection […]

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