Surprise medical bills have become a rallying point for healthcare advocates, patients and providers who are frustrated with oblique pricing practices and narrowing payer networks.
Here are 20 things to know about balance billing in 2017.
1. The practice of balance billing refers to a physician's ability to bill patients for outstanding balances after the insurance company submits a portion of the bill. Out-of-network physicians, not bound by in-network rate agreements, may bill patients for the remaining balance.
2. It is generally not a hospital requirement for physicians who work in the facility to contract with the same health plans. "We are sensitive to additional bills that patients may receive from affiliated physicians that practice at our hospitals," said Kimberly Johnson, director of communications for Brentwood, Tenn.-based TriStar Health, in USA Today. "We encourage those physicians to participate in the same insurance contracts in which our hospitals participate."
3. The practice of balance billing garnered increased attention from media and advocacy networks as consumers take on more financial responsibility for medical care. Under the ACA, many health plans narrowed their provider networks and cut out-of-network benefits from their product offerings to control costs and keep premiums affordable. This has increased some health plan beneficiaries' chances of receiving out-of-network care and reduced the health plan's financial responsibility for out-of-network care.
4. The Florida College of Emergency Physicians called upon the Federal Trade Commission Dec. 13, 2016, to investigate the practice of "surprise" balance billing caused by involuntary out-of-network care as a violation of federal law. The FCEP argued instances of network discrepancies between hospitals and their contracted emergency physicians was an "unfair and deceptive" business practice.
5. Under current law, Medicare has financial protections in place designed to safeguard Medicare beneficiaries from unexpected and confusing charges when they seek care from providers. These protections include the participating provider program, limitations on balance billing and conditions on private contracting.
6. In 2011, HHS Secretary nominee Rep. Tom Price, MD, (R-Ga.), introduced legislation designed to allow Medicare physicians to contract with patients for a set fee, then balance bill patients for any outstanding fees after Medicare submitted reimbursement. Dr. Price said the bill would bolster "paltry Medicare rates that threaten to drive physicians out of the program and leave seniors bereft of care." Critics argued the bill would drive up out-of-pocket costs for seniors.
7. Many physicians charge more than what Medicare reimburses, but visits with certain physicians are more likely to result in large surprise medical bills, according to a national study by Baltimore-based JohnsHopkinsUniversity. Anesthesiologists charged the highest average rates at 5.8 times the Medicare rate. Other specialists with high average charge rates included interventional radiology (4.5), emergency medicine (4.0), pathology (4.0), neurosurgery (4.0) and diagnostic radiology (3.8)
8. Patients who received treatment an in-network hospital ER received an unanticipated out-of-network bill 22 percent of the time, according to 2016 study in The New England Journal of Medicine.
9. Researchers found people in Texas were more likely to face unexpected bills for medical care than those in other states. Patients who received medical care in McAllen, Texas, had an 89 percent chance of receiving a surprise medical bill compared to a rate of nearly 0 percent in Boulder, Colo. Nationwide the chance of receiving a balance bill after an in-patient visit was 20 percent compared to a 34 percent chance in Texas.
10. Nationwide, 51 percent of ambulance rides potentially resulted in a balance bill in 2014.
11. Seventy percent of consumers with unaffordable out-of-network medical bills did not know the healthcare provider was out-of-network at the time they received care, according to a 2016 Kaiser Family Foundation study.
12. About 30 percent of individuals with private health insurance reported receiving an unexpected medical bill in the past two years, according to a 2015 Consumers Union address.
13. Among nonelderly insured patients struggling to pay medical bills in 2014, about 33 percent of medical bills were from out-of-network providers, according to KFF.
Balance billing at the state level
14. Federal law does not protect consumers from balance billing or surprise billing. About one-fourth of all states have policies to address at least some of the scenarios that typically result in unexpected charges.
15. Legislators in Rhode Island introduced bill H5012 in January 2017, which calls upon the state health insurance commissioner to devise an arbitration process for disputed medical bills arising from instances of involuntary out-of-network care.
16. Florida Gov. Rick Scott (R) passed legislation designed to limit and prohibit balance billing. Under HB 221, consumers cannot be charged more than the equivalent of in-network rates in emergencies and other instances of involuntary care — such as an out-of-network anesthesiologist for a scheduled procedure at an in-network hospital, according to a Palm Beach Post report. The bill exempts ambulance services.
17. Washington State Rep. Eileen Cody (D-Seattle) sponsored a bill to prevent balance billing in 2017. Bill HB 2447 would prevent out-of-network physicians from balance billing patients if the hospital where treatment occurred is in-network. Patients would pay only the expected in-network charges. Any disputes over contracts or out-of-network fees would be worked out between the insurer and the medical provider or facility.
18. California Gov. Jerry Brown (D) signed into law bill AB 72 September 2016, which aims to regulate payment rates between providers and payers in certain instances of care. The bill requires physicians bill a patient and his or her insurance company at up to 125 percent of the Medicare rate for involuntary out-of-network care. This would reduce the chance patients receive an extraordinary balance bill for involuntary out-of-network care. Providers have argued the bill.
19. Lawmakers in Montana have considered regulating payment rates between air ambulance services and insurers to mitigate instances of balance billing. Legislation proposed in January 2017 would require payers and air transport providers to settle payment disputes through legal arbitration and ban providers from balance billing patients at excessive rates.
20. Oregon lawmakers will consider two bills related to surprise hospital charges in the first session of 2017. House Bill 2679, sponsored by State Rep. Rob Nosse (D-Portland) would establish a hospital rate commission within the Oregon Health Authority to review and recommend whether to approve their charges as reasonable and penalize those with unreasonable charges. HB 2339 addresses balance billing by requiring insurers reimburse nonparticipating providers at a "reasonable and customary rate" to dissuade the provider from sending the patient an unexpected bill.
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