A Solution to Surprise Medical Billing

A Solution to Surprise Medical Billing
AP Photo/Don Petersen, File

Ronnie Shows represented Mississippi’s Fourth Congressional District from 1999 - 2003


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Imagine two people, with the same health insurance companies, walk into an emergency room. The patients have identical symptoms and receive the same diagnoses and subsequent procedures and treatments. Both patients should get an identical bill, right? But in reality, one patient could receive a bill where nearly everything is covered by insurance, and the other could receive a bill where little or nothing is covered. For some patients, this can be the difference between an emergency room bill that cost several hundred dollars, versus one costing tens of thousands. 

Insurance companies get away with this because a federal law -- called the Emergency Medical Treatment and Labor Act -- requires hospital emergency departments to care for all patients that arrive in an emergency room. Hence, insurers have leverage over the ER physicians. They offer ER doctors less than a fair reimbursement rate because they know if they don’t take it, the physicians still have to treat the patient. For example, in Texas, a recent study found that at more than 300 hospitals, not one ER doctor is covered by any of the state's largest insurers - even though the hospital is.

When a patient gets a massive bill from an ER visit, even though the hospital is in their insurance network -- but the ER doctor is not -- it is called surprise billing. Essentially, the patient is punished simply because the ER doctor they saw refuses to capitulate during a one-sided negotiation with a big insurance company.

This situation also puts ER doctors in an uncomfortable and an unfair position. On the one hand, they can take what the insurance company offers and accept less than what they believe is a fair reimbursement, or they can bill the patient for what the insurance company does not pay. ER doctors go into that type of practice because they want to help people in emergency situations, not because they want to create financial hardships for their patient. No doctor wants to order an expensive -- but potentially life-saving test or procedure -- that they know could result in their patient, or the patient’s family, facing medical bills that may jeopardize their ability to afford rent, tuition or even food. 

Surprise billing also has another, potentially more serious consequence: an insured patient could fear receiving a surprise bill and refuse to go to the ER when they are facing a health care emergency. This could create a potential hazard to the person’s well-being. Consider someone having a stroke, where we know that immediate treatment can mean the difference between a short recovery and a lifelong debilitating injury.

The good news is, is that surprise billing is not a hopeless problem. In fact, there is a common sense and practical solution. In Connecticut, the state established a minimum benefit standard that protects emergency patients from arbitrary payments for emergency care. In addition, there is an independent and transparent claims database called Fair Health to ensure everyone gets fair coverage. The database was developed after United Healthcare was sued by the state of New York for fraudulently calculating and significantly underpaying for emergency care in out of network situations. This ensures that ER doctors are reimbursed at a fair rate and that patients don’t end up getting a surprise bill because of an unexpected trip to the ER.

On a personal note, as a former Congressman, and a nearly life-long public servant in Mississippi, my friends, neighbors, family members and many other people continually reach out to me for help to cope with the costs of their medical care. Based on those conversations, I know surprise billing is a serious problem and one that needs to be fixed now. As the Congress and the White House continue to debate health care, I hope that this matter is addressed. We can try and fix it state-by-state, but I believe our elected leaders in Washington should follow Connecticut and create an open, fair and transparent database of all emergency care costs and reimbursement rates. It is the right thing to do, and the longer we allow the status quo to continue the more people will get hurt.



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