by Rachel Bluth, Kaiser Health News | Aug 7, 2019
Chances are, you or someone you know has gotten a surprise medical bill. One in six Americans has received these unexpected and often high charges after getting medical care from a doctor or hospital that isn’t in their insurance network.
It’s become a hot-button issue in Congress, and high-profile legislation has been introduced in both the House and Senate to make the medical providers and insurers address the billing question and take the consumers out of the dispute. That means doctor specialty groups, hospitals and insurers are among the stakeholders that could be financially affected by the outcome.
The effort has caught the attention of Physicians for Fair Coverage, a coalition formed by large companies—firms such as US Acute Care Solutions, U.S. Anesthesia Partners and U.S. Radiology Specialists—that serve as corporate umbrellas for medical practices. The group is running a $1.2 million national commercial about these congressional efforts. The ad began airing in mid-July.
The ad issued a warning: “What Congress is considering would cut money that vulnerable patients rely on the most. That means seniors, children and Americans who rely on Medicaid would be hurt.”
We wondered: Will any of the surprise billing proposals being debated in Congress really affect Medicaid and these patients—“shredding the safety net,” as the ad claims? So, we dug in.
We reached out to Physicians for Fair Coverage (PFC) to find out the basis for this claim, but the phone number listed on their website no longer worked. Several emails and a direct message on Twitter later, we connected with Forbes Tate Partners, the public relations firm that produced the ad. We were then referred to Megan Taylor, a spokeswoman for PFC.
“When we talk about the safety-net, we’re talking about the healthcare system that the uninsured and underinsured rely on—like emergency departments, where two-thirds of the acute care is provided to uninsured Americans and where half of the acute care provided to Medicaid and Children’s Health Insurance Program patients is delivered,” Taylor wrote in an email.
To be sure, studies have shown that ERs see a large share of vulnerable patients. But independent experts we spoke with still didn’t follow the ad’s logic.
“I’d like to think that I’m fairly well-informed about surprise billing legislation, but I’m struggling to understand what argument they are even trying to make here,” Benedic Ippolito, a research fellow at the American Enterprise Institute who has testified before a Senate committee on this issue, wrote in an email.
Focusing on the real trouble spot
The surprise medical bill legislation is an effort to help consumers who generally mistakenly thought they were getting health services covered by their insurers but instead find themselves dealing with an out-of-network provider.
The insurance often covers a small portion of services, and the patient is on the hook for the rest. It’s called a “balance bill.” That happens, for example, when people seek care at an in-network hospital but the doctor treating them doesn’t accept their insurance. The consumer can be responsible for paying the entire bill.
Most surprise bills come from specialty physicians—such as anesthesiologists, radiologists and emergency room doctors—like those in the practices represented by Physicians for Fair Coverage.
There are two major solutions on the table in the congressional legislation: arbitration, which would send the insurers and healthcare providers through an independent review to determine a fair price, and benchmarking. The ad doesn’t explicitly say so, but it’s referring to benchmarking.
Under this approach, when a doctor sees an out-of-network patient, the patient’s health plan pays the doctor the median of what other doctors in the area are paid for the procedure.
The ad paints a grim picture—complete with photos of children, families and even older patients in wheelchairs—of what will happen if Congress adopts benchmarking. It suggests insurance companies will offer doctors artificially low in-network rates, which, in turn, will bring down out-of-network rates. Those low rates will make it hard for doctors and hospitals to make up for uncompensated care or low payment rates from Medicaid and Medicare patients. The concern is that this will make it difficult for emergency rooms and rural hospitals to operate and force them to close.