Patient Responsibility News

Industry Groups Call on Protections from Surprise Medical Bills

The group issued a set of guiding principles based on the notion that patients should be protected from surprise medical bills.

surprise medical bills

Source: Thinkstock

By Sara Heath

- The healthcare industry must adhere to a set of core standards to protect patients from surprise medical bills, said a group of industry leaders in a new position statement.

The statement was issued by America’s Health Insurance Plans (AHIP), American Benefits Council, Blue Cross Blue Shield Association, Consumers Union, The ERISA Industry Committee, Families USA, National Association of Health Underwriters, National Business Group on Health, and the National Retail Federation.

Together, these groups called for better patient protections against surprise medical bills through adherence to core industry standards.

“Everyone in America deserves affordable, high-quality coverage and care, and control over their health care choices,” the group asserted. “Surprise medical bills undermine these values, putting the health and financial stability of millions of patients at risk every year.”

Surprise medical bills are invoices that a patient was not anticipating after a healthcare encounter. A patient may receive a surprise medical bill because she did not understand her insurance benefits, visited an out-of-network doctor or received an out-of-network treatment at an in-network facility, or was billed an amount she was not expecting because of limited price transparency.

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The group’s core principles operate under the notion that patients should be protected from surprise medical bills. To that end, the group said it supports legislation that would keep patients from being penalized for receiving care at an out-of-network facility during an emergency situation.

Often, patients receive care at an out-of-network emergency department or from an out-of-network specialist. This happens despite the fact that the patient visited an in-network hospital.

In these emergency cases, it should be illegal for hospitals to bill patients for care that is not covered by the insurer.

Additionally, patients should be informed when care will be out of network. Providers and payers alike should give patients clear, timely, and specific notification when the patient is about to receive care that is out of network. This will give patients the option to seek care that is a part of their insurance network.

When building policies to protect patients from surprise medical bills, industry leaders must be wary of increasing overall costs for patients or discouraging network participation. Patient protections must strike a balance in such a way that overall cost of care is not impacted, the group said.

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“Policy should encourage health plans and providers to collaborate by building networks that deliver high quality care and value,” the group noted. “Federal policy should focus on ensuring that providers are fairly compensated for their services, while encouraging them to participate in high-value provider networks.”

Additionally, payments to out-of-network facilities should be based on a federal standard. Policies must be flexible to adapt to certain states’ needs and standards, but also adhere to national guidelines to reduce surprise billing, the group said.

“Any federal standard for out-of-network payments should allow state flexibility for fully insured plans so long as a minimum federal threshold is achieved, but preserve ERISA’s national, uniform rules for self-funded plans,” they explained. “Any federal standard for payments to out-of-network doctors should apply to self-funded ERISA health plans, as well as in states that don’t enact their own standards for fully insured plans.”

These sentiments come as healthcare costs continue to increase and patients bear greater financial responsibility. Healthcare costs should not be crippling, the group said, and better transparency about patient payments will improve the overall system.

“Accidents and illnesses happen, and no medical emergency should break the bank,” they concluded. “By working together in accordance with these principles, we can ensure that every patient has the peace of mind that comes with knowing that they are able to get the best possible care, value, and personal control over their own wellbeing.”

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Surprise medical bills have become an significant healthcare talking point, especially over the course of that past year.

A September 2018 Kaiser Family Foundation poll shed a light on the issue, revealing that 67 percent of patients are concerned about surprise medical bills.

Unexpected bills proved an even larger concern than high premiums (18 percent), high deductibles (24 percent), and rising drug costs (22 percent). Worry about surprise medical bills also override financial worry about paying for other lifestyle needs such as rent or mortgage and grocery bills, the survey revealed.

A 2018 analysis from NORC at the University of Chicago found that 57 percent of patients have received a surprise medical bill, and 58 percent of patients perceive these unexpected charges to be their insurers’ faults.

This suggests that payers need better explanations of benefits and more transparency regarding patient billing, said Caroline Pearson, senior fellow at NORC at the University of Chicago.

“Most Americans have been surprised by medical bills that they expected would be covered by their insurance,” Pearson stated. “This suggests that consumers may have difficulty understanding their insurance benefits or knowing which providers are included in their plan’s network.”


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