Self-Pay Revenue Management

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Washington Working with Healthcare to Eliminate Surprise Medical Billing

August 2, 2019 - 3:10 PM

Surprise medical bills have been the focus of many discussions in Washington over recent months. They refer to services billed when a patient uses out-of-network providers in the following scenarios:

  1. Out-of-network physicians used to perform treatment at an in-network facility.
  2. Patients seeking treatment at an out-of-network hospital during an emergency.

Under the current legislation, providers can bill patients for the balance. These surprise medical bills cover the difference between the hospital's fees and the insurer's payment. 

They can be extremely costly and often come as a huge surprise to the patient. Sometimes the patient is not even aware they're using an out-of-network provider — or they don't have any control over the out-of-network services taking place. This means they were unable to give their consent before the treatment took place. As such, many deem the bills to be unfair on many levels.

Earlier this year, forty businesses wrote a letter to Washington, campaigning for change. The letter urges lawmakers to make the legal changes necessary to protect patients from surprise medical bills.

The letter focused on four key areas:

  • Protecting patients from surprise medical bills
  • The need for disclosure and transparency
  • Required reimbursement
  • How to handle ambulances and outsourced emergency departments

Network participation is an important part of our healthcare system. The organizations behind the letter make this clear. It's not about discouraging network participation but making the changes necessary to protect patients from crippling medical bills beyond their control.

Because the fact is, many patients don't have any choice in the provider when they seek medical treatment.

The organizations make a number of suggestions in their letter.

  1. They argue hospitals should provide the out-of-network costs before the patient books treatment. This applies to in-network providers using an out-of-network physician to perform the treatment.
  2. Hospitals should also disclose — on their website — any lack of resources likely to contribute to this scenario. 
  3. Although neither of these changes would eliminate the bills entirely, they would remove the surprise element. Patients would go into treatment with an understanding of the true costs. Therefore, any choices made by the patient are fully informed.
  4. The businesses also suggest a cap to the cost of emergency services performed by out-of-network providers. They suggest this should be set at 125% of the Medicare rate.
    Furthermore, out-of-network providers should accept in-network rates when performing procedures there.
  5. And finally, the businesses highlight changes required for the provision of emergency treatment.They argue ambulances are necessary to help people who require emergency care in urgent situations. Therefore, they should not be subject to balance payments.

Controversial incentives currently exist in relation to emergency treatment. This means, in some instances, in-network hospitals can profit from outsourced emergency treatment. Lawmakers should seek to eliminate these incentives.

Written by Emerald

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