Surprise
Most people like surprises, but not when the surprise is an unexpected medical bill. So, just what is a surprise medical bill? It is a bill from a health provider who is not a part of a patient’s insurance network of approved practitioners related to coverage. Usually this occurs when a patient is having a procedure at a facility within the insurer’s network and the health provider does not have a contractual arrangement with the insurance company, the HMO, or the PPO. They are not even employees of the hospital where the patient is undergoing tests or care. Typically, the surprise medical bills come from anesthesiologists, radiologists, pathologists, emergency room physicians, as well as some behavioral health specialists. Additional sources of “surprise” bills can be ambulance services, clinical laboratories, and special radiologic labs performing tests such as MRIs and PET scans. The rates for the services of these practitioners is much higher than the negotiated rates by the insurance company for similar services. The patient receives a bill for the service because the provider was not part of the insurer network or an employee of the hospital—Surprise!
Advocates for both sides—patients and doctors—have been lobbying Congress to influence the outcome of legislation concerning surprise medical bills. There are groups representing out-of-network providers such as TeamHealth and DoctorPatient Unity who present ads with scary scenarios such as ambulances arriving at closed rural hospitals. In turn, patient advocacy groups show equity firms (they control some of the out-of-network physician groups) making decisions about health care in a dark room. Despite the conflict, Kaiser Family Foundation stated that 78% of all adults want the surprise medical bills fixed even if it means lower payments to providers.
In 2017 the Bloomberg News reported that 18% of Emergency Room (ER) employer-based insurance bills were associated with surprise medical bills from ER physician groups. According to a research study from the University of Chicago, reported on the AARP website, one half of American adults have experienced surprise medical bills. Because of these egregious practices, President Trump directed Congress during remarks made in May 2019 to end these surprise medical bills (Kaiser Health News, May 9, 2019). Bipartisan Congressional efforts attempted to craft legislation that would satisfy the patients, the insurers, hospitals, and the out-of-network providers. Trying to balance the interest of patients to pay less and the practitioners to receive more money was not an easy task.
Unfortunately, the boat has already sailed for fixing the surprise medical billing problem in the near future. There had been hope from all Congressional parties that a compromise would be reached and that a bill would be included and signed by President Trump in the latest omnibus spending bill passed on December 20, 2019. It did not, however, contain the necessary hoped-for regulation that both Republicans and Democrats were working toward.
Another aspect of the surprise bills is the “balance bill”. This refers to out-of-network providers billing patients for services that were not completely reimbursed by the insurance companies. Nine states have outlawed this practice. Pennsylvania is not one of them. There is current legislation pending in the PA Legislature, HB 1862, and, if passed without amendments, it would give Pennsylvanians strong protections against surprise medical bills.
Because rural hospitals operate on very slim margins, they, too, are very concerned about the reimbursement elements of any legislation that might result in reduced payment to hospitals and to out-of-network providers who might be impacted and decline to see patients.
What to do now? Here are a few steps you can take before and/or after you receive your “surprise” medical bill:
Always ask the ordering physicians to use providers, suppliers, and specialty physicians in your insurance network.
Contact local ambulance companies to determine if they are in your network and when possible try to negotiate lower fees.
After receiving a surprise medical bill contact the billing office of the out-of-network provider and ask for a reduced fee. Also, contact your insurance carrier to solicit their help in this process.
Contact your state and federal legislators to urge them to support ending surprise medical bills.
Support a single-payer health program, which would eliminate surprise medical bills altogether since all providers would be in the same network.
Post script: This writer has personal experience with a surprise medical bill. After receiving an epidural injection by a radiologist at a local hospital, I was assured that he was in my network. In fact, he did not know that the group he worked with had recently rescinded their agreement with the insurer I used. The hospital charges were covered, but I received a very substantial bill for this procedure. I contacted the Radiology group’s billing department and was able to negotiate a reduction in the fee.
Mary Frances Colvin has spent forty years as a health care professional, working in hospitals, home health and hospice, the U. S. Food and Drug Administration, and the U. S. Centers for Medicare and Medicaid Services. She is an active member of the Health Care Task Force of Gettysburg Democracy for America.