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Senators Unveil Legislation To Protect Patients Against Surprise Medical Bills

This is a good idea and a necessary idea. It’s a problem that has been going on for years and getting worse as networks become tighter. However, the real problem is the very concept of networks.

Senators Unveil Legislation To Protect Patients Against Surprise Medical Bills

by Rachel Bluth, Kaiser Health News

With frustration growing among Americans who are being charged exorbitant prices for medical treatment, a bipartisan group of senators Tuesday unveiled a plan to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks

The draft legislation, which sponsors said is designed to prevent medical bankruptcies, targets three key consumer concerns:

Treatment for an emergency by a doctor who is not part of the patient’s insurance network at a hospital that is also outside that network. The patients would be required to pay out-of-pocket the amount required by their insurance plan. The hospital or doctor could not bill the patient for the remainder of the bill, a practice known as “balance billing.” The hospital and doctor could seek additional payments from the patient’s insurer under state regulations or through a formula established in the legislation.

Treatment by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network. Patients would pay only what is required by their plans. Again, the doctors could seek more payments from the plans based on formulas set up by state rules or through the federal formula.

Mandated notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital. The patients would be required to sign a statement acknowledging that they had been told their insurance might not cover their expenses, and they could seek treatment elsewhere.

“Our proposal protects patients in those emergency situations where current law does not, so that they don’t receive a surprise bill that is basically uncapped by anything but a sense of shame,” Sen. Bill Cassidy (R-La.) said.

Kevin Lucia, a senior research professor at Georgetown University’s Center on Health Insurance Reforms who had not yet read the draft legislation, said the measure was aimed at a big problem.

“Balance billing is ripe for a federal solution,” he said. States regulate only some health plans and that “leaves open a vast number of people that aren’t covered by those laws.

Federal law regulates health plans offered by many larger companies and unions that are “self-funded.”
Sixty-one percent of privately insured employees get their insurance this way. Those plans pay claims out of their own funds, rather than buying an insurance policy. Federal law does not prohibit balance billing in these plans.

Cassidy’s announcement cited two recent articles from Kaiser Health News and NPR’s “Bill of the Month” series, including a $17,850 urine test and a $109,000 bill after a heart attack. Cassidy’s office said, however, that this legislation would plug that gap.

In addition to Cassidy, the legislation is being offered by Sens. Michael Bennet (D-Colo.), Chuck Grassley (R-Iowa), Tom Carper (D-Del.), Todd Young (R-Ind.) and Claire McCaskill

In a statement to Kaiser Health News, Bennet said, “In Colorado, we hear from patients facing unexpected bills with astronomical costs even when they’ve received a service from an in-network provider. That’s why Senator Cassidy and I are leading a bipartisan group of senators to address this all-too-common byproduct of limited price transparency.”

Emergency rooms and out-of-network hospitals aren’t the only sources of balance bills, Lucia said. He mentioned that both ground and air ambulances can leave patients responsible for surprisingly high costs as well.

Lucia said he was encouraged that both Democrats and Republicans signed on to the draft legislation.

“Any effort at the federal level is encouraging because this has been a challenging issue at the state level to make progress on,” Lucia said.

KHN reporter Carmen Heredia Rodriguez contributed to this article.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Here’s how the legislation would work.

The draft legislation, which sponsors said is designed to prevent medical bankruptcies, targets three key consumer concerns:

1 Treatment for an emergency by a doctor who is not part of the patient’s insurance network at a hospital that is also outside that network. The patients would be required to pay out-of-pocket the amount required by their insurance plan. The hospital or doctor could not bill the patient for the remainder of the bill, a practice known as “balance billing.” The hospital and doctor could seek additional payments from the patient’s insurer under state regulations or through a formula established in the legislation.

2 Treatment by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network. Patients would pay only what is required by their plans. Again, the doctors could seek more payments from the plans based on formulas set up by state rules or through the federal formula.

3 Mandated notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital. The patients would be required to sign a statement acknowledging that they had been told their insurance might not cover their expenses, and they could seek treatment elsewhere.

Source: benefitspro.com

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3 replies »

  1. Physicians and hospitals will simply decide not to accept insurance. They will ask for payment up front, and/or won’t work in ER or perform emergency treatment.

    Many studies show that when prices are capped, physicians refuse Medicare and Medicaid patients. Expect the same result here.

    Not sure whether the us constitution allows Congress or the states to regulate contracts between private parties in this way.

    Like

    • That might have been true in the past. In our area, it now appears that the doctors are selling their practices to work for corporations. My wife used to work for a large cardiologist practice and they sold out. The admin support for keeping up with the insurance companies, billing coders, keeping on top of the legal requirements, electronic records, IT support, etc, just became too much. Nobody lost their jobs, they just had corporate support now to manage all these things more effectively. They still have more space for admin than treatment.

      As a kid, I remember going to a doctor in his house. He lived on the second floor and he had a nurse and a receptionist.

      My wife was treated at an urgent care center last year. We only saw one inclusive bill so it can be done. The corporation wants to do all the treating to get all the money.

      Like

  2. I think this legislation is overdue. I am always surprised at who gets paid. For a routine screening procedure, the surgical center, the doctor, and the anesthesiologist all submit bills. Or when you get an x-ray, the imaging center, some radiologist you never saw, and your own doctor that tells you what was in the x-ray, all submit bills.

    You would not stand for getting three bills from an auto dealership. One bill for use of the service bay, one bill from the guy who removes and re-installs the car tires, and then paying for another mechanic to fix your brakes. You expect that there would be one itemized bill for a brake job, not three. What if the tire guy was out of network and billed more than everybody else?

    Why is healthcare different? If you go to an in-network hospital, then everything should be in network and one bill should be itemized just like the auto shop bill would be. The hospital should not allow non-network doctors there.

    I think that the legislation should state that any out of network billing must be arbitrated for payment for an amount that is usual, customary, and reasonable. If the billing party does not agree then they must accept Medicare rates which are often lower than what most insurance companies will pay. This would stop the $17,850 urine tests. Most doctors accept 50-80% for their fee and labs as little as 20% from what I see them getting paid when billing my insurance company so you know that they will accept the small reasonable payments.

    Most hospitals, doctors, and auto mechanics cannot reasonably predict your costs until after the diagnosis but that should not give them a right to rape you while they cure you. At least most good mechanics will stop and tell you that you’ll need a $17k urine test before proceeding.

    Liked by 1 person

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