Patients are angry about 'surprise' bills. Here's how some hospitals are responding.

Some states have passed laws to settle disputes

Hospitals are employing various approaches to addressing patient frustration about balance billing, Bob Herman reports for Modern Healthcare.

Balance billing refers to when physicians submit a patient's claim to the insurance company and ask the patient to help pay the difference between what the insurer pays for out-of-network care and what the doctor charges.

Patients can face out-of-network bills when hospitals use contracted physicians or assistant surgeons that are not part of the same insurance networks as the hospital, either at EDs or for elective care.

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Such bills often come as a surprise—a March 2015 Consumers Union study found that 30% of privately insured U.S. patients had received a surprise medical bill, and that 25% of those patients received the bill from a physician they did not expect.

How hospitals, others are responding

Some insurers and hospitals are setting up systems to resolve billing disputes without involving the patient when possible. For instance, insurer Independent Health has set up a cost-containment division to address members' concerns about surprise bills, including by negotiating on patients' behalf with providers.

And some states have pursued legislative action—New York since April has required providers and insurers that disagree over an out-of-network payment to take part in an independent dispute-resolution process.

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Meanwhile, Florida-based Boca Raton Regional Hospital and Kentucky-based Jewish Hospital both require contracting physicians to contract with the same health plans as the hospitals in order to practice at their facilities.

But while some hospitals and physician groups aim to align the insurers that doctors and hospitals contract with, they can sometimes struggle to reach agreements.

Insurers contend that physician groups are demanding reimbursement rates that are too high. But American Medical Association President Steven Stack disagrees. "The real crux of the problem," he says, "is that health insurers are refusing to pay fair market rates for the care provided."

Stack also opposes the New York law as putting in place "a methodology to coerce physicians through yet another way to not receive sufficient payment" (Herman, Modern Healthcare, 8/29).

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