Compromise Is Key to Ending Surprise Medical Billing

With the coronavirus pandemic now ubiquitous across the United States — there are now more infections here than anywhere in the world — concerns about surprise medical billing remain as patients continue needing care, wherever they are. Although Congress came close to passing a bill to end this practice last year, ultimately lawmakers failed to find a broadly acceptable compromise. 

Surprise bills occur when patients unknowingly receive care from out-of-network providers or organizations such as emergency physicians, anesthesiologists and labs — even if they have gone to an in-network hospital. If their insurance company won’t cover the cost of that out-of-network care, patients are stuck with the bill.

In the coronavirus era, the chances for surprise billing still remain. At any point when patients need testing, medical care, hospitalization — or a transfer to a different hospital with enough available beds or ventilators, not to mention an ambulance to get there — if insurance doesn’t cover their care they could be hit with surprise bills.

And it’s not conjecture. A University of Chicago survey found that nearly 6 in 10 Americans have been hit with a bill not covered by their insurance, inflicting a significant financial burden on some patients. At a time when so many Americans are already financially strained given the broad economic shutdown as a result of the pandemic, the last thing they need is insurance to not cover their care. And as the ability of COVID-19 patients to access life-saving emergency and in-patient care is driving access and payment discussions, the issue of surprise billing is even more timely.

As the surprise billing discussions continue in 2020, the crux of the debate that persists is the method by which acceptable payment for the services that were delivered by out-of-network providers will be determined. 

Insurance companies seek to use a one-size-fits-all (benchmark) rate set at the median contracted payment for a medical procedure in a given geographic area. But some doctors and hospitals argue that benchmark rates will undermine the health care system because it would tip the balance in favor of insurance companies who could then arbitrarily reduce in-network payments. This, they argue, could reduce their payments so much that they might be forced out of business. For example, once the rate is set, insurers would simply cancel contracts with providers paid above the benchmark, forcing providers to accept the lower rate, without regard to quality of care or the local community’s care needs. There are concerns that failure to resolve the surprise billing issue that meets the needs of all critical sectors — patients, physicians, hospitals and insurers — will undermine the integrity of the delivery system infrastructure that provides security for all American communities.

Although we were pleased that many proposals have acknowledged the importance of including the use of Independent Dispute Resolution (IDR) to resolve rate disputes, there was no agreement on when such a process would be allowed and how the process would be structured to be fair to all sides. 

As we move forward to redressing the surprise medical billing conundrum and other health care delivery system inadequacies that compromise access to quality and effective health services, we will continue to encourage all parties to assure that their deliberations are governed by overarching values: patient protections and compromise.

Patient Protections: We encourage elected officials to be mindful that all legislative proposals must protect patients from additional out-of-network financial liability, while still ensuring that every American has access to quality medical care. The resulting law should offer greater financial security and stability for at-risk hospitals — primarily those serving rural, hard-to-reach communities as well as traditionally underserved urban ones — to preserve access and affordability for all patients.

Compromise: Compromise is essential for passing legislation through Congress. The primary disagreement between the supporters of the many surprise billing proposals in 2019 revolved around setting parameters for how insurers should pay for emergency or unscheduled out-of-network care that has already been provided and was out of the patient’s control. While one side of the debate proposes setting a payment standard — known as a benchmark — the other relies on establishing a process for determining the payment that considers the facts of the case and the entirety of the local health care market. Both sides of the debate, however, have come to recognize the importance of an Independent Dispute Resolution process for resolving these disputes.

As these deliberations proceed, the National Minority Quality Forum will continue to advocate for improvements in our health services research, delivery and financing system that enable the public and private sectors to operate most effectively to the benefit of patients and health care consumers. The use of Independent Dispute Resolution, rather than governmental price setting, is an integral component of that puzzle when it comes to resolving the problem of surprise medical billing. Especially as we navigate the tremendous health care challenges posed by the coronavirus pandemic, we must continue to work together to assure that the essential infrastructure of the American health services delivery system not only survives, but is positioned to evolve to meet our future needs.

Dr. Gary Puckrein is president and CEO of the National Minority Quality Forum.