In the ongoing debate about out-of-network balance billing, or so-called “surprise billing,” a recent national study found that the average anesthesiologist, radiologist, emergency physician, pathologist, and neurosurgeon charge at least four times what Medicare reimburses for the same services. Which means uninsured or out-of-network patients are on the hook for much higher balances than the federal government pays. In-network patients with high deductibles would at least benefit from contractual adjustments.
The Johns Hopkins University study of more than 400,000 U.S. doctors across 54 specialties was published in January in the Journal of the American Medical Association (JAMA).
According to a Consumer Reports article about the study, four states have passed laws against the practice of balance billing since 2015, including California, Connecticut, Florida, and New York. In Indiana, House Bill 1273 has been introduced by author Rep. James Baird and co-authors, Rep. Robert Heaton, Rep. Earl Harris, and Rep. Donna Schaibley, which would require noncontracted providers who render health care services in a contracted facility to inform insured patients in writing before rendering any services that the provider is noncontracted and that the patients can be billed for any services not paid by the insurance company.
Proposed legislation also is pending in Georgia, Washington, Utah, and other states. As well, on the federal level, Consumer Reports journalist Donna Rosato said the Federal Trade Commission is looking into the issue, at the request of Sen. Bill Nelson, D-Fla., and proposed House legislation—the End Surprise Billing Act—was reintroduced on February 2, 2017, by Rep. Lloyd Doggett, D-Texas.
According to Rebecca Parker, M.D., president of the American College of Emergency Physicians (ACEP), however, the study focuses on the wrong issues. “Several recent news reports present inaccurate, one-sided perspectives of the ‘surprise billing’ issue, exaggerating the severity of the problem and placing the blame on physicians,” Parker said in a statement issued in response to the JAMA research letter. “In fact it is the insurance companies who are gaming the system, and taking blatant advantage of their customers, who are our patients.”
To that end, ACEP claims that insurance companies have been “narrowing their networks of medical providers,” “denying payment for emergency patients as much as possible,” and making “significant reductions in insurance payments for emergency care.”
Emergency physicians would like to see states adopt consumer protection legislation similar to that recently passed in Connecticut, which requires the use of an independent and transparent charge database to determine reimbursement for emergency services received out of network. State and federal lawmakers also need to ensure that health insurance plans provide adequate rosters of physicians and fair payment for emergency services, ACEP claims. But the bottom line is that emergency physicians are asking that insurance companies simply provide fair coverage for their beneficiaries and be transparent about how they calculate payments.
As many as 22 percent of emergency department patients found themselves at an in-network facility but treated by an out-of-network physician, according to a 2016 study published in the New England Journal of Medicine.
Regardless of who’s at fault, Consumer Reports’ Rosato counsels patients to appeal to all parties involved to ease the burden of surprise billing, including educating themselves more thoroughly on the provisions of their insurance plan. Rosato’s four-step plan to avoid surprise bills includes:
- Talk to your doctor for in-network referrals and out-of-network negotiations.
- Call your health insurer before you go out of network to see what services are actually covered and to ask for an exception when needed.
- Understand what is covered in an emergency … before an emergency actually happens.
- Fight the bill with both the insurer and the provider, even filing appeals with the state insurance commission if necessary.
For physicians and their staff, knowing patients are being counseled to fight out-of-network bills means being prepared with policies and procedures for handling complaints, helping patients with insurance appeals, and offering payment plans and financial hardship policies for patients who just can’t pay their balances or at least not all at once.
For more tips about effectively managing out-of-network patients, review the following articles on the CIPROMS website:
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