Congress Tackles Surprise Medical Bills

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

In a rare bi-partisan effort this week, the House Health, Employment, Labor and Pensions subcommittee heard testimony regarding what can be done to prevent patients from receiving medical bills for which they are unprepared.

How can that happen? In several ways. For example, a patient can be seen in the Emergency room, pay their ER co-pay and expect the rest to be covered according to their insurance plan guidelines. However, they may receive a separate bill from the provider who saw the patient in the ER. Another common area in which this happens is when the Hospital is in network with the patient’s insurance plan, but the surgeon performing the procedure is out of network.

This is due to balance billing. While there is federal regulation around employer-sponsored insurance, there are state laws that govern balance billing, which is less regulated.

Frederick Isasi, the executive director of Families USA, a national nonprofit, nonpartisan organization dedicated to the achievement of high-quality, affordable health care for all Americans testified at this panel this week. He stated, “It is the providers and the insurers, not patients, who should bear the burden of settling on a fair payment.” Current solutions require patients to file complaints and go through an arbitration process.

The idea behind this legislation is to make more incentives for providers to opt to be in-network. Also, there should be a “limit [as to] how much they can be paid in out-of-network scenarios to make it less attractive.” Another suggestion is to cap reimbursement for out-of-network services at 125% of the current year Medicare fee schedule.

The solutions offered, however, did not seem to make any headway, particularly as far as Rep. Susan Wild (D – Pa.) stated, “The solutions I’m hearing don’t sound workable in the context of our present medical system.”

Balance billing can be detrimental to providers as well. Trying to collect patient balances after the fact greatly reduces the likelihood of receiving the payment. Oftentimes providers are left taking a payment plan or percentages off their balance to get the balance paid, but often, end up turning balances over to a collection agency. If a patient then files for bankruptcy, the provider will never be paid at all.

What some resolutions you can think of? One idea is better eligibility and benefits done by hospitals prior to procedures to make sure both the hospital and provider are in-network and making the patient aware of what their potential balances could be prior to surgery. However, this could discourage patients from receiving the medical treatment they desperately need. No doubt, there is a long way to go to reduce the hurdles of surprise billing to patients.



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