$5,751 for an ice pack. $20,000 for an insured patient's trip to the hospital for a broken arm and some tests. In response to scenarios like these, the American College of Emergency Physicians on Monday proposed a six-point plan to "take … patient[s] out of the middle" of surprise ED bills.
What's going on?
Patients are most likely to receive surprise medical bills when they're treated by a doctor who isn't in their insurance network. In some cases, a patient, who might not be cognizant of what's happening, is taken to an out-of-network facility. In other cases, the facility itself might be in-network but the doctors who treat the patient are not. In cases like these, once the insurer pays a "reasonable" rate to the out-of-network provider, the provider bills patients for the remaining cost.
Patients who challenge the bills often get caught between competing priorities between hospitals and insurers. Insurers often shift the responsibility to hospitals, saying they're responsible for ensuring patients do not receive surprise bills for out-of-network care, while hospitals cite "weak insurance networks" for the high costs.
The issue has gained attention in the media and at the federal policy level in recent months. Vox's Sarah Kliff spent a year reporting on surprise ED bills, and senators from both sides of the aisle have vowed to address the issue. Sens. Maggie Hassan (D-N.H.) and Bill Cassidy (R-La.) released bills to tackle surprise medical billing that are currently making their way through Congress. The Senate health committee even named surprise out-of-network medical bills as a top policy priority for 2019. And President Trump last week announced a desire to tackle the issue.
The 6-point proposal
As politicians increasingly eye the issue, ACEP is now offering its own suggests for tackling the problem.
In the proposal released Monday, ACEP said that "by law, emergency physicians will treat any patient, regardless of their ability to pay" and, since "patients can't choose where and when they will need emergency care ... they should not be punished financially for having emergencies."
The proposal goes on to outline the six policy recommendations that are designed to "protect[t] patients when emergency care is out-of-network." ACEP in the proposal said any legislation on surprise ED bills should aim to:
- Prohibit balance billing by barring providers from asking patients for payments for out-of-network emergency care;
- Take patients out of insurer-provider billing disputes by requiring insurers to pay coinsurance, copayment, and deductible directly to the provider and collect any additional payments from the patient;
- Ensure patients do not pay more out-of-pocket for out-of-network emergency care than they would pay for in-network care;
- Require insures to convey plan details for members clearly;
- Require insurers to clearly convey patients' rights related to emergency care; and
- Establish an arbitration process to settle network issues in order to exclude patients from billing disputes between insurers and providers.
ACEP in the proposal also requested that HHS establish a Commission on Access to Quality and Affordable Emergency Care that will study and analyze recently enacted bills. The committee would advise Congress on: the adequacy of patient protections under the new legislation; whether the bill's processes for out-of-network care include provider protections that ensure patients' access to quality care; and the potential benefit of offering supplemental funding to emergency physicians for uncompensated care.
What stakeholders are saying
ACEP said the proposal will "truly take the patient out of the middle" of insurer-provider billing disputes and make it easier for patients to navigate the billing process.
However, the proposal drew criticism from the insurance industry. A spokesperson for America's Health Insurance Plans said that "solving the surprise medical billing issue for consumers must be about real solutions that work, not an exercise of shifting blame." The spokesperson added, "We believe that by working together, we can get patients out of the middle and let them focus on getting better while making coverage and care more affordable for everyone." At the time of comment, the spokesperson said AHIP was still reviewing the proposal.
David Anderson, of the Duke University Margolis Center, in a blog post also pointed out that the proposal targets only one of the two types of claims that an ED bill usually generates—which are the facility fee for overhead costs and the professional claims for doctor's time. The proposal, according to Anderson, only takes aim at the professional claims, not the facility fee, which Vox has reported can contribute to surprise bills (Haefner, Becker's Hospital Review, 1/28; Cohen, Inside Health Policy, 1/28, [subscription required]; Kliff, Vox, 1/29; Anderson, "Balloon Justice," 1/30).
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