Covering Surprise Medical Billing: Tips to Help Reporters

Background Information

Surprise balance billing happens when an out-of-network health care provider bills a patient directly for treatment, appointments, services or therapies that were not covered by the patient’s insurance plan. This is often a surprise, because the patient is typically unaware that the services were out-of-network for their health insurance provider, even when they are receiving care in facility that is in their network.

Increasingly, surprise bills are becoming more common. In July 2020, the U.S. Department of Health and Human Services noted that research indicates that 41 percent of insured adults nationwide were surprised by a medical bill in the past two years alone, and that two thirds of adults worry about their ability to afford an unexpected medical bill.

Sadly, it’s often people facing medical crises who get hit with surprise bills.  A January 2017 study[i] published in Health Affairs found that 20 percent of emergency department admissions and 14 percent of outpatient visits to the emergency department resulted in surprise bills. A March 2019 Government Accountability Office study of air ambulance transports found that 69 percent of the 20,700 transports examined were out of network and noted that these patients often faced hefty bill balances in the tens of thousands of dollars.

And inpatient services are not exempt either. Sometimes, even the most diligent patient may be unaware that a lab, physician, or another health care provider, who works with or at an in-network facility or their health care plan, is actually out of network. A Kaiser Family Foundation study found that one in 10 people had received a “surprise” medical bill from an out-of-network provider in the past year.

3 Things to Know                                                

Tip #1 – Compare apples to apples. Billing practices can vary wildly, even at the same facilities and among different insurers, and it’s important for reporters to compare numbers carefully. Ask sources for paperwork and billing records. The New York Times reported in June 2020 on two friends who were tested for Coronavirus on the same day in the same emergency room – one was billed $199 and the other was billed $6,408. Again, this was for identical tests.

Tip #2 – Pay attention to state and federal protective actions. More than half of U.S. states have taken action to limit surprise billing practices. The Commonwealth Fund tracks state actions to help patients with a helpful clickable map. Stat News has noted that states are working as living laboratories on the matter, and the National Council of State Legislatures also follows the issue. A federal fix to the surprise billing issue has been speculated about on Capitol Hill for years, and while there was hope in early 2020 that a solution might be found, legislation to halt surprise billing remains elusive. There is widespread agreement on Capitol Hill that something should be done to address the issue, but Congress has not been able to agree on how much insurers should pay providers when a surprise bill occurs. Check statehouse and federal news agencies for updates, as the rules are changing to protect patients and their families.

Tip #3 – Look for solutions that help patients. State governments are trying to offer solutions in the form of dispute resolution, mandating rates for reimbursement, and other mechanisms. The federal government is considering several options, and many thinktanks are weighing in too. Untangling the web of state and federal mandates and ideas – and boiling things down to real actionable solutions that can benefit patients is important.

What Could be Done to Address Surprise Medical Billing Issues

A group of patient advocacy organizations has been pushing Congress to act on surprise billing during this session. While they have not endorsed any one bill, we all agree that any legislation, at a minimum, must:

  • Hold Patients Harmless: Any policy addressing surprise billing must ensure that patients are held financially harmless. When patients receive services from an out-of-network provider for which they have the reasonable expectation that the service was performed in-network (for example, services performed at an in-network facility, or services ordered by an in-network provider), the patient should incur no greater cost-sharing than if the service was performed by an in-network provider. Any such cost-sharing should accrue to in-network deductibles and out of-pocket caps. Any solution should also ensure costs are not simply passed along to patients through higher premiums or out-of-pocket costs.
  • Apply Protections to All Insurance Plans: Surprise billing protections should apply to all commercial health insurance plans, including individual, small group, large group, and self-insured plans as applicable, as well as plans that do not qualify as “qualified health plans” under the Affordable Care Act.
  • Apply Protections to All Surprise Bills for All Covered Services: Protections should apply to all surprise bills, regardless of the amount of the bill. Protections should apply to devices that may be provided to a patient while in their provider’s office. A surprise bill of any amount can be challenging to patients and their families.
  • Apply Protections to All Care Settings: Surprise billing protections should be applicable regardless of provider type or care setting. Policies should not limit these protections to just emergency services, hospital services, or certain types of specialists.
  • Require Transparency in Addition to – Not Instead of – Surprise Billing Protections: Increased transparency for patients is not a sufficient way for policymakers to address the problem of surprise billing. In the vast majority of surprise billing cases, the affected patient has little ability to seek an alternative in-network provider, even if given more information. While our organizations support greater transparency requirements for plans and providers, such requirements are insufficient in and of themselves to meaningfully protect patients from surprise bills.
  • Conduct Additional Research: Surprise billing can occur for a variety of reasons, including the inadequacy of a plan’s provider network. Policymakers who enact surprise billing protections should also consider requiring data collection on the incidence of surprise billing to determine whether additional policies and protections are warranted (for example, enactment of more robust network adequacy requirements).
  • Strengthen State Protections Instead of Weakening Them: Any federal protections against surprise billing should set a floor to ensure that at least this level of protection exists in all states, but not pre-empt stronger state-level protections where these rules apply.
  • Protecting Patients Who Utilize Emergency Transportation: The National Health Council and its member patient advocacy organizations are deeply concerned about the impact of balance billing practices on individuals who require emergency transportation. Emergency transportation services reduce transport time for patients during life threatening situations and are a critical component of successful treatment for individuals experiencing a serious health event. Patients in these situations have no choice over who provides care or how they are transported and are frequently balance billed as a result. Policymakers should craft policies that protect patients in all health care settings, including emergency transportation settings.

Terminology & Resources

04/09/2020 – Ending Surprise Billing – a letter to Senator Majority Leader McConnell, Minority Leader Schumer, House Speaker Pelosi, and Minority Leader McCarthy.

02/24/2020 – Surprise Medical Billing Update

Subject Matter Experts Available for Interview

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