Congress Must Stop Surprise Billing the Right Way

Keith C . Wolaridge (Courtesy Photo)

By Keith C . Wolaridge

Letter to the Editor

Now that the U.S. House of Representatives has gotten impeachment out of the way, it is working on some business that got bottled up last year. Members of both parties, such as Minority Leader Kevin McCarthy (CA-23) and Majority Leader Steny Hoyer (MD-05), are considering what needs to get done before they go hit the campaign trail. And one persistent, nagging item is surprise medical billing.

A Stanford University study found that that the problem is getting more expensive and more widespread. The study looked at patient billing between the years of 2010 and 2016. It found that over 42 percent of patients admitted to emergency rooms or hospitals got hit with surprise bills and that the dollars charged are going up – from a mean of $804 in 2010 to $2040 in 2016.

The reasons behind the plague of surprise medical billing are complicated but it is in no way due to negligence on the part of patients with insurance coverage. Patients almost always confirm that a facility is “in network.” Later, they are hit with a surprise bill because while the facility was “in network,” one or more of the providers that treated them were “out of network.”

The problem is most acute in the emergency room. By law, providers are obligated to treat patients yet are prohibited from telling them if their insurance won’t cover a test or procedure. Out-of-networks providers submit their bills, insurance companies don’t pay, and the patient gets stuck with the bill.

The financial stress resulting from surprise medical billing negatively affects every aspect of our lives. As a Trustee for the Panama-Buena Vista Union School District for the past ten years, I see families struggle to focus on their children’s education because they are preoccupied with the hardships that come with an unaffordable surprise bill.

Most members of Congress agree the problem requires a solution urgently. But if Congress acts urgently and wrongly, it could make matters worse.

One approach under consideration in Washington would allow the federal government to set “benchmarks” in which insurance companies would reimburse providers at deliberately low “in-network” rates. However, this approach would be a disaster for hundreds of hospitals in rural areas treating underserved populations.

The key to quality, affordable care is a meaningful Independent Dispute Resolution (IDR) process. Here’s how it works: When an insurance company receives an out-of-network bill, it is prohibited from passing it along to the patient. Instead, the bill is sent over the Internet to a qualified mediator empowered to resolve the billing dispute. Through this simple, transparent online process, the insurance company presents its offer and the provider can make his or her

case, for a different amount. The process rewards moderation because the mediator has to pick one of the two figures. If the insurance company shoots too low, or the provider too high, they only help the cause of their rival disputant.

Such an approach has worked in New York, which enacted an IDR law in 2015. Since then, patients have saved over $400 million in emergency services and out-of-network billing has shrunk by 34%.

Congress must act on surprise medical billing. The best solution would include a meaningful IDR component that is fair to all parties – fair to providers, to insurance companies, and above all to patients.

Keith C . Wolaridge is a Trustee for the Panama-Buena Vista Union School District.