Policymakers and healthcare providers have directed their attention towards ending surprise medical billing in recent years. Surprise billing affects approximately one in five insured individuals throughout their lifetimes. Although lawmakers and healthcare providers agree that surprise billing is an issue, with coronavirus concerns still rising, hospitals have asked Congress to refrain from passing any new legislation on the topic until after the pandemic slows down.

What is surprise billing?

When a patient unintentionally receives medical care from a physician outside their insurance network, they may receive a surprise bill. This typically happens in one of three ways: a patient seeks out emergency care outside of their insurance network due to travel or limited option, a patient receives care from an out-of-network provider while visiting an in-network healthcare facility, or a health plan deems a patient’s emergency care as unnecessary. 

Surprise medical bills are a combination of insurance company charges for using out-of-network physicians and “balance billing,” which covers the difference between the provider’s full rate and what the insurance company is willing to pay. They often amount to thousands of dollars in medical expenses that may upset a family’s entire livelihood. 

A Team Effort

Congressional efforts to address surprise medical billing were put on hold due the U.S. appearance of the novel coronavirus back in March of this year. Among them were H.R. 5800, the Scott-Foxx Ban Surprise Billing Act, and H.R. 5826, the Neal-Brady Consumer Protections against Surprise Bills Act of 2020. Both propose the implementation of a benchmark payment rate, which would ensure that providers were paid a set rate based on the median cost of in-network health services in their geographical location. 

Hospital groups have requested that policymakers instead opt for an arbitration process, in which the insurance company and healthcare provider would propose a fair cost for services received that would assist a third-party arbitrator to decide on a fair price. Some congress members have voiced concern over arbitration delaying the claims process and increasing overall costs; however, some states like New York have already adopted arbitration on a small-scale due to the equality and impartiality the system provides. 

In a letter to congressional leaders, a group of hospital executives wrote, “We urge Congress instead – if it chooses to move forward with legislation to address surprise medical bills – to enact a proposal that would completely remove the patient from the middle of payment disputes between insurers and providers, while also preventing the federal rate-setting approach that tilts the scales in favor of insurers.”

Moving Forward

The American Hospital Association predicts that hospitals will lose over $323 billion in 2020 directly due to the outbreak of COVID-19. The association advised Congress to ensure that all patients are provided a comprehensive and up-to-date list of in-network providers and related information and focus on educating patients about their health plan coverage.

Macee Hall

Originally from the snow-capped Rockies, Macee moved to Texas in 2016 to pursue an undergraduate degree in Strategic Communication. She currently serves as a writer and editor for Empower Brokerage, as well as the marketing manager for Preferred Senior Advisors. Macee is also working on her Master’s degree in management, and hopes to inspire others with her passion for telling stories through varied digital and print marketing efforts.