Surprise Medical Bills
By Ibby Smith Stofer
What if you had a medical condition that required you to undergo surgery and while you were recovering you received a bill for over $150,000? Or what if you had a heart attack and were taken by air ambulance from your favorite off-the-grid fishing spot? Would your insurance cover all of the bills, part of it, or none? How would you pay for any uncovered bills?
These are real-life questions and experiences that American patients deal with all too often. They have insurance and yet they have no control over the surprise that awaits them after receiving care that they believed would be covered by their insurance plan.
When enrolling for insurance, we usually check to ensure that our preferred physicians are part of what the industry calls “in-network.” These are the physicians, labs, facilities and other services that have agreed to the negotiated fees for services. You can visit your insurance providers websites to check what insurance your preferred providers accept. However, the urgent nature of care, and the belief that if you are receiving treatment from an “in-network” provider can put patients into tricky situations. It is only after discharge and sometimes a few months after the fact that the reality of what is or will be covered by your health insurance comes to light. The anesthesiologist, the surgeon, and others may work at the “in-network” facility, but not participate in the network. In other words, those professionals are free agents who bill your insurance company independently and collect any shortfall from you, the patient.
The topic of healthcare insurance and billing has been part of heated debates for many years. This is not surprising when you learn that these bills are often the cause of personal bankruptcy and other significant financial hardships for individuals and families. The time and effort that it takes to dispute the bill with their insurance company, the physician’s office, collection agencies, and more is exhausting. It is a rigorous maze of phone calls, emails, and letters. It takes stamina, organization, patience, as well as computer skills that not everyone can manage.
Surprise bills are also known as balance billing practice. This term refers to collecting the difference between what the provider charges and what the insurance company reimburses. There are different views on whether this is a reasonable business practice. Currently, the federal government is holding discussions and trying to find a solution from these increasing medical bills that often put patients in bankruptcy or worse.
Twenty-five state governments have enacted legislation to protect their constituents from this practice. However, not all legislation encompasses all events that can provide the dreaded “surprise bill.” Additionally, federal law (ERISA) exempts self-insured employer-sponsored plans from any state regulations. Currently, this leaves many families without protection.
What solutions are being discussed?
Doctors, The American Health Association, The Association of Health Insurance Plans, and others have opposed some of the solutions being discussed. Some examples are a bundled rate for emergency services, a national reimbursement rate for out of network services, or arbitration between the independent service provider and the healthcare facility.
Patient advocates take the opposite view. The Brookings Institution report found that about 20% of emergency department visits and 10% of elective inpatient stays involve at least one out of network provider. In addition, about 50% of the ambulance rides are out of network. These groups feel it is time to get the patient out of bearing that burden.
As with most discussions on healthcare in America, there are opposing interests and the solutions seem to be elusive. There does not appear to be any simple or easy answers. There are numerous articles floating around and the very fact that it is a discussion in Congress, demonstrates the serious nature of “surprise billing.”
I believe we need to take the patient out of the equation and limit what out of network providers can charge. Healthcare is a huge percentage of American’s budgets and they have no way to plan for or cover these unexpected charges. Speak up to your state and federal legislators and let them know your opinion on the subject. Patients cannot continue to be surprised and forced into financial hardship due to the surprise bill from medical providers that are not accepting their insurance, without their knowledge or consent.
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