Have you ever ordered something and then been shocked at the sticker price? This happens in health care, but one unique element has recently gained a lot of attention in Congress. It is called surprise billing. What is it? And who is it that is surprised?
Surprise billing is the term used for an insured person who uses healthcare, only to later discover that the provider they saw was out-of-network and they are responsible for much more expense than they bargained for. There are two main categories of surprise billing.
One category is when a patient is responsible for more cost sharing—deductible, copayments, and coinsurance— when they receive health services out-of-network. These differences can be substantial. You may be responsible for 40% of the cost of rather than the 10% or 20% you would have been responsible for if you had care from in-network providers.
The second category is balance billing. Here is how it works. In-network providers negotiate with insurance companies to provide services at a discount from full price. Typically, then, the providers are not allowed to bill patients for the difference between the discounted price and the full price. This is not true for out-of-network providers who can bill for the full amount. Both categories can happen for the same services, leaving you, the patient, with a hefty bill.
So, why aren’t patients just more careful about staying in-network? In the current system it is almost impossible. Let’s say you are hospitalized after an accident and your physician orders a consult from a neurologist. The neurologist may actually be out-of-network, even when seeing you in the same facility that your in-network physician uses. Now let’s say they decide you need surgery. Your anesthesiologist may be out-of-network as well. They, along with emergency medicine physicians, are frequent sources of surprise billing. Yet, most people are not aware of this. Also, most of us who use emergency departments or are having surgery are not in the frame of mind to consider each member of the health care team and query them about their network status.
Bipartisan members of Congress have proposed different bills to stop surprising billing. In general, insurance companies, employer groups and consumer groups support ending this practice. Many hospital groups and physician groups oppose it, saying it will harm patients. What do you think?
Luthi, S. (2019, June 11). Physician, hospital groups gear up for fight on surprise billing. Modern Healthcare. Retrieved from https://bit.ly/2KJQqQK
Pollitz, K. (2016). Surprise medical bills. Kaiser Family Foundation. Retrieved from www.kff.org/person/karen-pollitz/
After reading this I think I’m hearing some of the same problems I hear concerning the Rhode Island school system. Systems working in systems, working with systems, mountains of regulations and no one entity that has authority. Everyone is saying the patient\student is their number one priority, yet in many cases the patient\student is the one suffering from their negligence in fixing the broken product.