Cathy Mahaffey is CEO of the non-profit Common Ground Healthcare Cooperative, Wisconsin’s largest individual market carrier serving 20 counties in Eastern Wisconsin.
If you follow health policy or political news, you may have heard mention of “surprise bills,” a health care billing practice that threatens the financial security of many Wisconsin families. Two recent studies show why this issue is getting more attention now than ever, as the practice is becoming more common at the same time the bills climb higher and higher.
What are Surprise Bills?
Surprise bills typically occur when a consumer seeks care at an in-network facility only to find later that an out-of-network provider was brought in for part of the treatment. It turns into a surprise bill when the out-of-network provider receives the market rate of payment from a health plan and then bills the patient for the remainder. The balance bill can amount to tens of thousands of dollars in some cases, while the consumer usually has no say in the matter and is most often unaware until the bill arrives in the mail.
It also happens in emergency situations, when the consumer has no choice or say in who treats them. It’s a common occurrence with ambulance transport for example, or when a medical emergency strikes while someone is traveling.
Not all providers balance bill patients, but when it happens, it can be shocking and financially devastating to families. It happens to health care consumers across the board, whether they are insured through an individual carrier like ours or through a self-funded employer plan. As a cooperative health plan, we try to intervene on behalf of our members hit with balance bills and try to work out a reasonable payment with the provider, but we are rebuffed about half the time. Real-life stories involve on-call emergency surgeons, air ambulance, anesthesiologists, pathologists and overnight observation providers outsourced by hospitals.
Will Congress Act?
President Trump, Democrats and Republicans in Congress agree that something needs to be done to end surprise medical bills for patients. But so far, that’s where the agreement ends. Employers, insurers and consumers strongly disagree with doctors, hospitals and health care investors when it comes to the proper way to work out payment. It has divided lawmakers in Congress and has resulted in a slow-down of the legislation.
Congress should focus on the needs of consumers. When an out-of-network provider is working at an in-network hospital, it just makes sense that patients should be informed and the provider should accept the agreed-upon, in-network rate of payment.
When it comes to non-network life-saving emergency care when a patient can’t possibly choose, Congress should set a reasonable benchmark for payment. It should be transparent, and not set so low that providers lose money, but not so high that providers are discouraged from participating in networks. The Senate Health, Education, Labor and Pensions (HELP) Committee threads this needle by passing legislation that would require health plans to pay out-of-network providers the local median contracted commercial rate for the same service.
Providers are pushing hard against this and are seeking an amendment to the bill. They prefer to force employer plans, insurers and providers through an arbitration process where payments could be worked out behind closed doors. It keeps the payment rates between providers and plans secret and requires that money be spent to create the process and administer it.
Those that have heavily invested in the profit side of health care just want to kill the bill. After spending millions on an attack ad campaign, it looks like they may succeed.
Contact Your US Senator and Congressperson
Common Ground Healthcare Cooperative, like The Alliance, acts in the best interests of its members when advocating for policy solutions. We want this bill to pass in the coming months to protect the financial health of our members, who are individual people buying insurance on their own. We want it to pass to protect employees insured by your plans too. Unfortunately, we are running out of time to get this done before Congress gets mired down in election year politics.
Please consider joining forces with us to urge Congress to pass surprise billing legislation in the coming weeks without arbitration. Keeping prices secret is the root cause of many problems with the US health care system, and Congress should reject the arguments for arbitration outright in favor of an open, transparent solution that puts the needs of consumers first.
It’s time for Congress to stand up for patients, not special interests. Employers, please join us in helping the Wisconsin delegation hear their voices. Business is a critical ally in this cause, and it may not happen without you.