Healthcare legislation regarding surprise medical bills has dominated the headlines lately. You will likely hear of this during the coming months if you have not already.
What Is A “Surprise Medical Bill” Anyway?
What is a surprise medical bill, you ask? Most people in America enroll with a commercial insurance payer if they are not eligible for Medicare or Medicaid. Many insurance plans provided by commercial payers require patients to visit specific physicians, hospitals, and other facilities that have contracted with the payer to get the maximum benefit from their policy. “In-network” physicians and facilities provide services at prearranged pricing for patients who subscribe to the insurance plan.
Problems may arise when a patient finds themselves in an emergency situation where circumstances dictate the patient is unable to choose an in-network provider.
Let’s say there is an auto accident during an out-of-state trip. A patient is injured and had to be transported to the nearest hospital. The patient had no choice in the facility or the physicians that treat them in this case. As a result, the patient may receive a substantial bill because the facility is not in the policy’s network. Furthermore, the physicians treating the patient may not be in the policy’s network. Many policies have greatly reduced or no out-of-network reimbursement provided, so….surprise!
What Healthcare Legislation Will Address
In the previous example, the patient essentially had no choice on where to go for care due to emergency circumstances, and this is what the U.S. Congress is attempting to address. Frank Pallone (D-NJ) and Greg Walden (R-OR) have introduced a bipartisan bill in the U.S. House of Representatives that would significantly change what providers and facilities could expect a patient to be billed following emergency treatment.
However, this particular piece of healthcare legislation goes further. It also will address non-emergency services provided by physicians who may not be in a patient’s network even when the hospital is.1
Spotlight On Hospital Bad Behavior
Reporter Sarah Kliff recently completed a year-long investigative survey of emergency room practices for numerous facilities. She found during her research the largest public hospital in San Francisco was out-of-network with all private health insurance. This seems so unbelievable that I had to read it twice. I just wanted to ensure I had read correctly! At that point, I had to ask myself, “Should a public healthcare facility be allowed to operate with no network affiliations? Shouldn’t they be required to maintain in-network status with at least a few major commercial payers?”2
Only now can we begin to understand why healthcare legislation must be enacted to protect patients from surprise medical bills.
California and New York have already enacted measures to prevent surprise medical bills in their states. Texas has healthcare legislation recently passed by the state Senate, SB12643, which is expected to be signed into by Governor Greg Abbott.
You can hear more about the Texas bill on the Grand Rounds Legal Podcast: “Staying Profitable and in Compliance” with Jerri Lynn Ward, J.D. where Ms. Ward interviewed revenue cycle professional Greg Thrash, CMRM at Innovations in Medical Revenue.
So Where Do We Stand Today On Surprise Medical Bills?
As previously stated, the House of Representatives currently has a bill under construction at the time of this article. It appears that another bipartisan bill will be presented for a vote on June 26th in the Senate Health, Education, Labor and Pensions Committee by sponsors Lamar Alexander, (R-TN), and Patty Murray, (D-WA).
It will be interesting to see the outcome of this vote, but consider this: When is the last time both parties in both houses of Congress agreed on anything? There is good reason to believe that no matter which bill prevails healthcare legislation will be enacted that will protect all of us from surprise medical bills.
- “Surprise medical bills: House releases new bill after Trump … – Vox.” 14 May. 2019, https://www.vox.com/policy-and-politics/2019/5/14/18622825/surprise-medical-bills-trump-house-health-care-legislation. Accessed 14 Jun. 2019.
- “Hospital ER fees: They’ve been secret. We’re uncovering them. – Vox.” 27 Feb. 2018, https://www.vox.com/2018/2/27/16936638/er-bills-emergency-room-hospital-fees-health-care-costs. Accessed 14 Jun. 2019.
- “TX SB1264 | 2019-2020 | 86th Legislature | LegiScan.” https://legiscan.com/TX/bill/SB1264/2019. Accessed 14 Jun. 2019.
- "Surprise medical bills: House releases new bill after Trump ... - Vox." 14 May. 2019, https://www.vox.com/policy-and-politics/2019/5/14/18622825/surprise-medical-bills-trump-house-health-care-legislation. Accessed 14 Jun. 2019.
- "Hospital ER fees: They've been secret. We're uncovering them. - Vox." 27 Feb. 2018, https://www.vox.com/2018/2/27/16936638/er-bills-emergency-room-hospital-fees-health-care-costs. Accessed 14 Jun. 2019.
- "TX SB1264 | 2019-2020 | 86th Legislature | LegiScan." https://legiscan.com/TX/bill/SB1264/2019. Accessed 14 Jun. 2019.