Surprise Billing - Patient gets hit!

Here is what we know about surprise billing. One in 10 insured adults have said they’ve received a surprise bill in the past year. The average surprise bill is more than $600, which is more than 40 percent of families would be able to pay without borrowing or selling something. Many surprise bills are thousands of dollars, with some greater than 600 percent more than Medicare would have paid for the same service.

Groups of physicians—particularly emergency physicians and anesthesiologists—stay out of insurance networks, levy outrageously high bills on unsuspecting patients, and maximize their revenue. This is their business model. These groups of physicians have organized to gain market power, often with the backing of a private equity firm. They take advantage of the fact that, in most cases, patients do not get to choose them: Ancillary providers such as emergency doctors or anesthesiologists, which patients typically do not choose, are more likely to send a surprise bill.

There is a lot of finger pointing going on in Washington, and the surprise billing debate has been framed as a battle between providers and insurers. But the only people really hurt by surprise billing are patients, and sometimes their employers if they step in to pay the bill. The system is clearly stacked against patients. Keep in mind that the average family of four in the US makes roughly $60,000 a year, and we are talking about physicians that are highly compensated; for example, emergency physicians were paid an average salary, after expenses, of $352,697 in 2017, while radiologists were paid an average of $488,338. Who will Congress choose to protect?

President Donald Trump speaks while looking at medical bills during an event on medical pricing in the Roosevelt Room of the White House in Washington, D.C., U.S. on Thursday, May 9, 2019. Trump said that Congress should pass legislation to stop Americans from getting surprise medical bills, adding momentum to a bipartisan issue that has aroused the ire of patients around the country.

Patients often assume that their health insurance will cover emergency care or major procedures. They're caught by surprise when they find out that they’re not fully covered.

Of all the euphemisms in U.S. healthcare billing practices, so-called "balance billing" may take the cake. Balance billing, better known as surprise billing, happens when a patient receives care from a doctor or hospital outside of her insurer's network. Subsequently, the doctor or hospital bills the patient for the amount insurance didn't cover. Needless to say, these bills can be hefty. They add insult to injury, tormenting the American consumer of healthcare.

Surprise bills are symptomatic of the extraordinarily complex ways in which healthcare prices are set in the U.S. Supposedly, balance bills reflect the difference between in- and out-of-network costs to the insurer. The often unchallenged assumption is that health plans contract with doctors, hospitals, and pharmacy networks to reduce the costs of care and keep premiums low for consumers. While undoubtedly in-network contracts save money for insurers, it's unclear whether and how much of the savings are passed on to the consumer. Since when did your premiums go down, or your out-of-pocket costs for that matter, even if you had all your care done in-network?

There is bipartisan support to end surprise billing. Last month, representatives Frank Pallone (D-NJ) and Greg Walden (R-OR) jointly released a draft bill that would prevent patients from facing surprise charges after emergency room visits, or even after receiving non-emergency medical care.

Full transparency for consumers requires piecing together the cumulative cost of treatment, and the portion covered by the insurer. Additionally, there needs to be timely communication on billing between healthcare providers and insurers.

Streamlining healthcare payments may result in lower administrative costs for insurers and providers, and "most importantly, patients will be better informed and relieved of the burden of exorbitant surprise bills."

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