Surprise Medical Billing

Surprise medical billing, also called balance billing or out-of-network billing, can occur for many reasons. Emergency medical services have been blamed for the majority of these Surprise Bills although they occur in non-emergent situations and have be associated with other medical specialties as well.

 

Emergency physicians want patients to be held harmless and understand that the reason these bills have become more prevalent are due to systematic efforts by health insurers to maximize their profit and minimize covered health services. Health insurers have contributed to this problem by increasingly narrowing their networks, refusing  to negotiate contracts with physicians, abusing the EMTALA mandate and retroactively denying coverage for Emergency Department visits and by expanding high deductible health insurance plans - cost shifting more of health care expenses to patients who already are paying record health insurance premiums.

Congress has been working on legislation to end Surprise Billing but one of the proposed solutions, known as Benchmarking, will put Emergency Medical Care access and patients at risk, threatens to worsen physician shortages and lead to hospital closures.

SURPRISE BILLING SOLUTIONS:

 

We support: IDR

  • A solution that holds patients harmless, is fair to all parties and does not give health insurance companies more power, profits and ability to bully patients and physicians.

  • IDR has been implemented in New York State and shown to address balanced billing while protecting access to medical care. Patients are held harmless with this solution and administrative costs are covered by whichever party in an arbitration dispute loses.

  • An arbitration or Independent Dispute Resolution (IDR) process that is accessible to Emergency Departments and not set at an unattainable threshold.

       (Ex. $1250 for a charge as cited in the Energy & Commerce bill is a false arbitration included         for political purposes only and is non-functional as almost all emergency             

       department charges are under $500)

  • Designation of a fair, third party to act as an arbiter, who is not controlled by either insurance companies or hospital associations and that the losing party bringing a case to arbitration pays for administrative fees related to arbitration. (This results in no additional costs to the state or patients and disincentivizes outliers in charges or reimbursement rates.)

  • Use of a third party healthcare claims database (Ex. FairHealth) that is not funded, owned or influenced by health insurance companies.

We Oppose: Benchmarking 

  • ​A solution that puts patients at risk by decreasing resources for Emergency Departments (i.e. on call specialists, staff, RNs while already facing a shortage)

  • Will lead to Hospital and Emergency Department closures leading to less Emergency Medical care access.

  • Decreases ability to recruit and retain quality trained Emergency Department physicians and staff

  • Increases wait times for patients with Emergent conditions

  • A solution used as a Trojan Horse for Big Insurance company endorsed, government rate-setting not just in Emergency Medicine but for all specialties.

  • Gives the already bloated and profitable Insurance companies all negotiating power and ability to further abuse the unfunded EMTALA mandate.

  • Will decrease ability for hospitals and physicians to negotiate contracts 

  • Lead to greater consolidation via Contract Management Groups (CMGs) and higher health care costs

Any Surprise Billing Solution Must:

  • Ensure patients are held harmless and protected

  • Not risk the national safety net of Emergency Medical care

  • Direct Insurance companies to honor the Prudent Layperson Standard and cover emergency medical care

  • Enforce health insurance network adequacy

  • Avoid rate setting

  • Encourage transparency about network status from insurance companies and physicians

  • Continue to allow for patient choice in elective out-of-network medical care 

 
information on Surprise Billing

Benchmarking Will Result in a Race to the Bottom:

Analysis and Graphics by Amy Cho, MD, MBA

 
 
Benchmark graph

Surprise Billing and Emergency Medicine

Analysis and Graphics by Amy Cho, MD, MBA

 
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Why EMTALA matters in Surprise Billing solutions:

Analysis and Graphics by Amy Cho, MD, MBA

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