Surprise Medical Billing – And How Congress Should Stop It

Jim Verros
Small business owner and communications specialist from California’s San Joaquin Valley. As a veteran of multiple campaigns he frequently provides political analysis on television and radio.

There are good surprises and bad surprises. Surprise medical bills are without a doubt the bad kind.

They come most often after a patient receives care at an in-network hospital only to be treated without their knowledge by an out of network physician. The patient’s insurer and provider try to work out a price, and if they can’t, the patient ultimately receives a surprise bill. And these bills are usually quite steep. One study found that they are typically “2.5 times what most health insurers pay and more than 3 times hospitals’ actual costs.”  

If this seems like a scam to you, it’s because it is. But it’s also legal and has happened to a startling number of Americans. By one estimate, nearly 40 percent of U.S. patients have been hit with unexpected out-of-network fees. If we want American healthcare to work for everyone, then this legal scam needs to end.

Fortunately, many in Congress – including House Minority Leader Kevin McCarthy – realize what a monstrous deception surprise billing is. There are a number of bills to address this problem working their way through Congress, but not all of them are ideal. 

One would settle reimbursement rates using median rates for in-network care. This would mostly benefit the insurance industry by essentially allowing them to set their own prices, which would slash provider pay. And what happens when you slash pay for doctors, physicians, and emergency facilities? It causes doctors to leave and hospitals to close. This is exactly what has happened here in California since our state passed its own rate-setting bill. 

The better idea working its way through Congress is a bill with the most straightforward name – the STOP Surprise Medical Bills Act. It has bipartisan support and incorporates an approach that has proven successful in New York.

Here’s how it would work: When in-network healthcare providers present your insurance company with an out-of-network bill, your insurance company would pull the facility and provider into binding arbitration. The arbitrator would be instructed to help the two parties reach an agreement while keeping the interest of you, the patient, paramount. Best of all, you never get stuck with a surprise bill.

In states where an independent dispute resolution process already exists, such as New York, it has proven to have a preventative effect: most cases are resolved before arbitration is necessary. When cases do go to arbitration, the decisions have been evenly split between insurers and providers. Put simply, it’s a fair process with fair outcomes—outcomes that the patient never has to worry about.

I am confident that conservatives in Washington, like Kevin McCarthy, who has been a steadfast leader on healthcare issues in Congress, will help end the legal scam of surprise billing. With a little guidance from voters, they may recognize that the STOP Surprise Medical Billing Act is the right way to ensure basic fairness prevails.

 

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