February 8, 2019
What are surprise medical bills and why do they happen?
A surprise medical bill is an unexpected bill a consumer receives from an out-of-network doctor after receiving services at a facility the patient chose because it is in his or her health plan’s network. In these cases, the patient does not know or cannot control whether some care was provided by a practitioner who is not in the network.
For example, if a pregnant woman goes to a hospital to deliver a baby, she will typically have chosen the doctor delivering her baby, but not the anesthesiologist giving her pain medication. If the anesthesiologist is not in-network, she may receive a separate, unanticipated bill from the anesthesiologist. These bills can amount to hundreds – even thousands – of dollars.
How common are surprise medical bills?
Estimates suggest that as many as 15 percent of patients have received a surprise medical bill following a hospital stay. To help shield consumers, insurance companies will usually try to work with the out-of-network physician to reach an agreement on a reasonable payment.
Surprise medical bills are particularly common in emergency room settings. In fact, several studies have found that roughly one in five emergency room visits involve care from an out-of-network doctor. Certain specialties tend to be associated with surprise bills including pathologists, anesthesiologists, radiologists, emergency room physicians and assistant surgeons.
What is being done to address surprise bills?
The Blue Cross Blue Shield Association has joined with consumer and employer groups, as well as others in the healthcare industry, in endorsing core principles to protect patients from receiving surprise medical bills. The principles call for federal legislation to address surprise billing and help ensure that patients are informed, engaged and protected from excessive costs for the care they need.
BCBSA also is working with lawmakers to find solutions and is recommending specific changes that can better protect consumers. These include prohibiting balance billing, the practice of billing a patient for additional charges after an insurer has already paid the medical practitioner, and requiring medical facilities to provide patients with written documentation of their rights regarding balance bills.
We believe that patients should not be put in a position where they are forced to consent to care that knowingly is out-of-network when they do not have any alternative options available to them.
Furthermore, hospitals and doctors are in the best position to notify patients of their rights, since health insurers do not have visibility into who a patient sees until a bill is submitted for payment.
Health plans are also continuously working to ensure patients have access to robust networks so they can obtain the right care in the right setting from an in-network practitioner. In many cases, when patients unexpectedly receive care from an out-of-network physician at an in-network hospital, health plans will try to work with that physician to come to an agreement on a reasonable payment. They will also try to encourage physicians to join the health plan’s network to reduce the risk of a repeat situation for another patient.
However, many states do not prohibit physicians from balance billing or only prohibit it in limited circumstances (e.g., for emergency services). That’s why it’s vital for Congress to act on a federal solution.