ACT NOW: Stop Surprise Medical Billing

Surprise medical bills leave already vulnerable consumers exposed to unexpected costs – sometimes reaching into the thousands of dollars.  This occurs when consumers, usually through no fault of their own, unknowingly receive medical care from a health care provider who is not a part of their health insurance plan network.  That care is often delivered through in-network facilities. 

These medical services could be provided by emergency department physicians or on-site specialists like radiologists, pathologists, or even anesthesiologists.  When this happens, the patient is billed directly by the out-of-network (OON) provider for the balance of charges remaining after that consumer’s insurance company has reimbursed the provider in accordance with their negotiated health benefit.  Unfortunately, this happens far too often, leaving consumers responsible for exorbitant charges despite their having taken the appropriate steps to seek out in-network care.

Unless the necessary consumer protections are enacted, these costs will be felt downstream, affecting how much consumers pay for their health insurance coverage, including premiums and other out-of-pocket costs.  Today, Americans make more than 140 million annual visits to emergency departments – and, more than one-third of those result in referrals to specialists.  Studies have shown that surprise medical bills are most likely to come from emergency department physicians or specialty providers.  Further, these groups have been found to charge significantly higher rates than Medicare, driving up costs for everyone. 

Federal lawmakers in both the U.S. House of Representatives and U.S. Senate have taken up the issue, and are currently considering bipartisan legislation to better protect consumers from surprise medical bills.  These bipartisan efforts would protect consumers from receiving surprise medical bills from providers by limiting reimbursement to OON providers to no more than the median negotiated rate that is paid to in-network providers for the same or similar service in that geographic area.

This reimbursement benchmark would encourage providers to be in-network.  As it stands, OON providers receive total payments that are significantly higher than in-network rates, largely because of their ability to directly charge consumers for the balance of the bill.  This practice leaves little incentive for OON providers to join health plan networks, which ultimately leads to higher premiums for consumers and fewer resources being available to reimburse the providers who do in fact contract with health plans.

Unfortunately, several health care provider organizations are working hard to change the bipartisan legislation that the House and Senate are currently considering to include an anti-consumer arbitration model that will increase costs and create unnecessary administrative burdens and complexity across the health care system.  Analysts at the American Enterprise Institute (AEI) point out that arbitration would only exacerbate the problem of surprise medical bills and continue to push these excess costs onto patients.

That’s why it’s so important that lawmakers hear from stakeholders.  We need our Health Action Network members to take action today and urge their federal elected officials to support legislation that protects consumers from surprise medical bills by focusing on the median negotiated rate without the unnecessary and harmful inclusion of an arbitration model.  

Take Action