Surprise medical bills – why allergists should care

Hardly a week goes by when the popular media or a health-oriented publication tells the story of a patient who has been victimized by a surprise medical bill. Typically, the stories will involve a patient who has been taken to an out-of-network emergency department (ED) and been subjected to sky-high fees - even though the patient had no control over where the ambulance took him or her. Another commonly told story is of a patient who conscientiously selects an in-network hospital and an in-network surgeon to perform a procedure, only to find that the anesthesiologist – whom the patient had no choice in picking – is out of network, subjecting the patient to exorbitant out-of-network fees. 

Although the surprise billing issue has, until recently, been a state issue, it is now firmly on the doorstep of the United States Congress and the White House with loud calls to do something to deal with this problem. Bi-partisan groups of federal legislators have called for federal protections so that patients are financially protected from these high out-of-pocket expenses incurred through no fault of their own.

Most physicians have largely ignored this issue, concluding that it doesn’t affect them or their specialty. This is a problem for the hospital-based physicians to deal with, not office-based physicians – WRONG!

Health plans are attempting to exploit the political sympathy for those who are truly victims of surprise billing to ban a practice they have long sought to eliminate: balanced billing. At the urging of health plans, several of the legislative proposals aimed at dealing with the surprise billing problem define a surprise bill as any out-of-network charges a patient may experience, regardless of whether it occurs for the reasons cited above, or because the patient consciously chose to obtain care from an out-of-network physician. 

Although physicians lost the Medicare-balanced billing debate years ago, they have successfully fought back against efforts to ban or limit balance billing when it came to commercial insurance. 

Even though most of the examples of surprise billing would not occur in the allergy/immunology specialty, the preferred solution being promoted by health plans would adversely impact most allergy/immunology physicians. Health plans are promoting a solution that would limit what the out-of-network physician can collect to a percentage of Medicare. The most common is 120% of Medicare. This wouldn’t just be for ED physicians, anesthesiologists or other hospital-based specialties, it would apply to any out-of-network situation, including physician offices where the patient knowingly has gone to an out-of-network provider.

Some physicians have said balance billing 120% of the Medicare allowable wouldn’t be too bad. But consider for a moment, the precedent that would be established. If these proposals are adopted, the government, in addition to having a fee schedule for Medicare, would virtually be setting a fee schedule for all payers.

What would prevent health plans from going to the next Congress and presenting a proposal that states, “We think balance billing 120% of Medicare is too high and patients need more financial protection. We suggest you lower it to 110% of Medicare,” and so on and so on until finally, physicians are getting less than Medicare reimbursement.

Health plans appear to be using the public furor over surprise bills to achieve things well beyond the problem. If health plans went to Congress straight-up and said, “we want you to impose limits on what physicians can charge,” they’d get little traction. But linking this solution to the surprise billing problem, suddenly has members of Congress – from both sides of the aisle – falling all over themselves to protect consumers. But they are paying little attention to what they are buying into, let alone setting themselves up for in a few years.

Think this is far-fetched? Here’s a description of a bill introduced late last year by a senator who is actively engaged in the surprise bill debate. This is from a summary of the bill provided by that senator’s office:

… the Reducing Costs for Out-of-Network Services Act of 2018, would cap the amount that hospitals and physicians could charge uninsured patients and out-of-network patients who have individual market coverage.

Surprise billing is a significant problem and there are reasonable steps Congress can take to address situations where patients find themselves in an out-of-network situation through no fault of their own. But physicians need to look more closely at what some of the legislative proposals would define as a surprise bill and, more importantly, the limits they would place on what the physician can charge the patient. Quite often, the definitions of a surprise bill are far broader than the examples used to justify limits on those types of bills.

The Advocacy Council is closely monitoring this issue. We will be meeting with federal legislators and HHS officials this week to express concerns about some of the surprise billing solutions being discussed and will keep you advised of progress on this issue.

Advocacy Issue: 
Billing, Coding & Payments
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