WASHINGTON (AFP) – People with private health insurance will almost see the trauma of a “surprise” medical bills, thanks to the coronavirus settlement passed by Congress.
Fees that can range from hundreds to tens of thousands of dollars come from doctors and hospitals outside of a patient’s health insurance plan. It is estimated that about 1 in 5 emergency visits and 1 in 6 inpatient admissions will result in a surprise bill.
Although lawmakers from both parties have long agreed that the practice amounts to arbitrary billing, the pressure war between doctors and insurers has thwarted a compromise, allowing the impasse to become a symbol of dysfunction in Washington.
“This has been a very distressing issue for families for years,” said Karen Pulitz, a health insurance expert at the non-partisan Kaiser Family Foundation. “Some of these bills are onerous, and all of them are hurting people as being completely unfair.”
A compromise will get patients and their families out of financial trouble by restricting what can be paid for off-grid services to fees based on in-network fees. The amount that consumers pay will be calculated from the annual deductible within the network.
Insurance companies and service providers will submit their billing disputes to an independent dispute resolution process, which will follow certain guidelines. The main provisions of the legislation will enter into force on January 1, 2022.
“Overall, keeping the consumer out of this problem and forcing service providers to compromise is a positive thing,” said Egan Kemp, a policy expert at Public Citizen, a liberal advocacy group. Although states have been moving to curb surprise bills, federal action is needed because states do not have jurisdiction over large employer plans that cover tens of millions of workers and their families.
The main elements of legislation would:
Keeping patients away from sudden bills resulting from emergency medical care. This will apply if the patient is seen in an off-network facility, or if he is being treated by an outside-network doctor in a network hospital. In both cases, the patient can only be billed based on the price of their plan within the network.
Protection of patients who are admitted to a hospital within the network for a planned procedure when a doctor outside the network intervenes. This can happen when the surgeon is called in to help in the operating room, or if the on-call anesthesiologist is not part of the patient’s plan.
Non-network providers are generally required to give patients 72 hours notice prior to the estimated fee. Patients will have to agree to receive out-of-network care for the hospital or doctor to then bill.
Preventing air ambulance services from sending surprise bills to patients for more than the cost-sharing amount within the network. Air ambulance fees are becoming a bigger problem in states where patients have to travel long distances to reach the best hospitals. However, ground ambulance services will not face the same restrictions, and the legislation only calls for further study of their billing practices.
The compromise legislation included two years of action by dozens of lawmakers from both parties and major committees, including energy, trade, ways and means in the House, health, education, work, and pensions in the Senate.
Surprise bills plague patients and their families when they are most at risk – after a medical emergency or after a complex surgical procedure. Patients are often able to negotiate lower fees by working with their insurance companies and medical provider. But this process usually takes months, adding to stress and anxiety. Sometimes the order does not work out and invoices are sent to the collection agencies.
Senator Maggie Hassan, Dr. R no. Often times, they have to fight these bills at the same time they face a medical crisis. “
According to the Kaiser Foundation, 18% of emergency visits result in at least one off-network fee for people covered by large employers, as well as 16% of inpatient admissions within the network. New York and Texas are among the highest.
The problem is a direct result of rising healthcare costs. To try to keep insurance premiums in check, insurance companies have set up networks of hospitals and doctors who agree in advance about payment levels. But some high-demand physicians, such as emergency room physicians and anesthesiologists, have an incentive to stay away from at least some networks in an effort to increase their earning potential. This dynamic is becoming more and more complex as profit-seeking investors buy into medical practices that have significant billing leverage.
Insurers were uncertain about the settlement, saying that the structure of the dispute resolution process could lead to higher payments that then lead to higher premiums. Some Democrats had advocated using a pre-set price list to resolve billing disputes, but that shocked Republicans and other Democrats as being too close to setting a government rate.
“Our for-profit healthcare system really enables companies to make money in the various gaps of the system,” said Kemp, a healthcare advocate from Public Citizen. “This is a day full of hope. I thought that between insurance companies and service providers, there would be no sudden billing legislation passed.”
Public programs like Medicare and Medicaid prohibit or restrict these billing practices.