Surprise Medical Bills (an update)

Juwen Zhang reported on this for the NYTimes case, but thought I would update this article with recent events.  First, a quick definition:

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.  These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others.  In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network.

In this March 17, 2016 article from the Kaiser Family Foundation, they conducted a survey among insured, non-elderly adults struggling with medical bill problems and found that charges from out-of-network providers were a contributing factor about one-third of the time.  Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care [my emphasis].

Data on the prevalence of surprise medical bills and costs to consumers are limited.  The Affordable Care Act (ACA) requires health plans in and out of the Marketplace to report data on out-of-network costs to enrollees, though this provision has not yet been implemented (see footnote in the article).  However, research studies offer some clues as to the prevalence and cost to patients due to surprise medical bills.  The list is worth reading.  New York has been investigating this since 2011. 

What is new are the Federal and State protections against surprise medical bills

Policymakers at the federal and state level have expressed concern that surprise medical bills can pose significant financial burdens and are beyond the control of patients to prevent since, by definition, they cannot choose the treating provider.  Various policy proposals have been advanced, and some implemented, to address the problem.  These include hold harmless provisions that protect consumers from the added cost of surprise medical bills, including limits or prohibitions on balance billing.  Others include disclosure requirements that require health plans and/or providers to notify patients in advance that surprise balance billing may occur, potentially giving them an opportunity to choose other providers.  Read the article for more on the federal response and other links.