Surprise Medical Billing

Blog Articles · Feb 21, 2020 · Healthcare

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Topline: Congress should solve the surprise medical billing (balance billing) problem by giving patients more control over their health care costs with transparent information about medical prices, enforcing truth in advertising, and placing limitations on balance billing for emergency services.

Background: Surprise medical bills are a source of frustration for many Americans. Patients who schedule medical care from network physicians or at network hospitals sometimes receive bills from doctors outside the network such as anesthesiologists, radiologists, or pathologists. Or a patient may be transported to a nearby emergency department, only to learn that the hospital was not in his/her insurance company’s network. In cases like these, patients are saddled with bills that can be very high, potentially running into tens or even hundreds of thousands of dollars.

Proposal: In order to best address surprise medical billing, Congress should implement three reforms. First, Congress should require healthcare providers to supply a good-faith estimate of the cost of scheduled medical care before it occurs, unless the patient declines an estimate. Providers that refuse to supply an estimate before providing care should not be able to “balance bill” afterward. Second, Congress should protect consumers against false and misleading information by establishing penalties for any insurer that falsely represents a facility as being in-network, and for any facility that presents itself as being in-network if doctors balance-bill for services they provide at that facility. Third, Congress should use existing regulations to ban balance billing for non-network emergency care. In these limited, emergency situations, Congress should require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Talking Points:

  1. Current House and Senate proposals rely on sweeping and unnecessary federal price regulation, rather than market-based alternatives, to eliminate balance billing. Both would force doctors and insurers who have not contracted with each other to accept rates set in contracts they haven’t signed.
  2. Our proposal guarantees no more surprises without resorting to heavy-handed measures.
  3. Congress should solve the balance-billing problem by giving patients more control over their medical care with accurate information about medical prices.