You would think that passing legislation to prohibit surprise billing would be easy and pretty non-controversial. After all, who wouldn’t agree that an innocent patient who is trying to use the in-network system shouldn’t get snookered with a bill from an out-of-network doctor who by happenstance becomes part of the care team? For example, the on-call radiologist or emergency room doctor who is out-of-network is asked by the facility to participate in a surgical procedure and later bills a non-discounted amount for services which now fall into the out-of-network bucket. Out-of-network charges often have large deductibles and coinsurance, so the patient is left with an uncovered charge. This is especially egregious since these out-of-network doctors might be lurking around, fully knowing that the patient isn’t going to have a choice – they are already under or about to go under the knife.
So, Congress is planning to pass a bill that prohibits patients from getting billed without affirmative consent. Makes sense, EXCEPT what happens now? Under what basis is this doctor to get paid? It would seem easy to establish a protocol such as average in-network reimbursement for the procedure billed but this can vary materially by network contract. And if the patient is protected is the plan also protected? In other words, if the patient can’t receive a surprise bill would the excess be shifted to the payer plan or would the provider have to accept the reduced payment?
The proposed bills will no doubt provide a dispute resolution procedure. And this isn’t easy either. Should a standard be established? If so, what standard? If not, should there be an arbitration provision to clear up disputes? A leading broker group, of which I am a member (the National Association of Health Underwriters [NAHU]), advocates that an arbitration provision would add significant costs to the system since there would be little incentive for the practitioner not to grieve a low reimbursement. They believe that the law should be clear. I agree and also believe the patient and the plan should be protected.
Just one more example of how difficult it is to fix healthcare.