Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Compromise vs. greed in ending surprise medical bills

Robert Laszewski
Policy
December 12, 2019
23 Shares
Share
Tweet
Share

There are few things in our health care system that are more unfair than surprise medical bills. Consumers think they have good coverage and are getting treatment in their health plan network only to get a huge unexpected bill in the mail because it turned out that something like the anesthesiologist at their recent surgery wasn’t covered.

How were they to know that? As you’re sitting on the gurney about to be rolled into surgery, do you need to do a provider roll call asking each to confirm their network status?

The worst of these examples often has to be with air ambulances sending patients bills for tens of thousands of dollars they had no reason to expect. As the patient lays there with burns over 60 percent of their body and they need to be transferred to the regional burn center, are they supposed to say, “Before you put me on the helicopter, what is this going to cost?”

Now, every politician I know of says that all of this needs to end.

But, they are yet to end it.

Both sides on this issue have legitimate concerns.

Insurance companies, employers, and union plan sponsors (payers) find themselves caught between their customers and health care providers in these circumstances. Some of these providers actually have business strategies to purposely not be in a network looking to charge anything they want in these situations. That is not to say health plans couldn’t be doing a lot better in making their networks clear to patients. Why in this world of real-time data can’t health plans and providers confirm that all providers who are part of my procedure are in the network at the point of service?

Hospitals, doctors, and other providers worry that some of the proposed solutions would de facto toss them into the payers’ networks at the network’s typical payment rates, thereby disenfranchising them from being able to negotiate what their payment rates should be.

Like everything else in the American health care system, it’s complicated.

When you have two sides offering legitimate but diametrically opposed arguments, the solution can only come through compromise. And, I will suggest, when such a circumstance occurs in a matter involving public policy, it is the role of the legislature to impose a compromise that, as its first priority, meets citizen needs.

Led by Senate Health Committee Chair, Lamar Alexander (R-TN) and the House Energy and Commerce Chair Frank Pallone, Jr. (D-NJ) and ranking member Greg Walden (R-OR), it sure looked to me like a powerful bipartisan group in Congress did just that.

They offered a solution to this problem that was responsive to both sides’ arguments and would end up holding patients harmless from all of this.

If a patient is out of network and the provider refuses to accept the plan’s payment:

The provider would have to accept a minimum payment reflecting the plan’s market-based median in-network negotiated rate for the service in the geographic area where the service was delivered.

This compromise would force the provider to accept a payment amount, but it would be the median of all amounts that had already been negotiated in good faith in that market with a large number of providers.

But, providers could still have a reasonable objection arguing they should be able to negotiate their own rate, and perhaps their circumstances justify a higher rate than the median.

Of course, they can always enter negotiations with the payers to be in their network in the first place.

But failing that, the proposed compromise would also give providers an out:

If the median in-network rate payment was above $750, the provider or the insurer could elect to take the matter to binding arbitration with an independent dispute resolution service. To keep people from gaming the system, a party could not go to arbitration for the same service more than once in 90-days.

This is what I would call a compromise. Neither side gets all that they want, both get something reasonably resembling what they have asked for (payers wanted a median rate, providers wanted arbitration), and the consumer/patient caught in the middle no longer has to suffer from all of this.

So, what has been the response to this so far:

Insurance companies, employers and union plan sponsors don’t like it — the Coalition Against Surprise Medical Bills — said anything with arbitration wasn’t good enough, “The result of arbitration is that consumers, employers, unions, and taxpayers pay the price” pointing to what they said was abuse by providers in an existing New York arbitration system.

On the other side, providers generally objected. The American Hospital Association said the proposal would offer an “arbitrary … reimbursement rate,” jeopardize patient access to hospital care,” and “provide a huge windfall to commercial insurance companies at the expense of community hospitals.”

Under pressure from the payer lobby on one side and the provider lobby on the other, leading members of Congress have been leery of supporting the proposed compromise. For example, the ranking Democrat on the Senate health committee, Patti Murray (D-WA), didn’t join in support of the bill reportedly because Democratic Senate Minority Leader Chuck Schumer (D-NY), responding to hospital lobbying in his state, waived her off.

Much has been made of the current toxic political environment in Washington, DC, and the inability to get things done because of it.

But here is an example of bipartisan leaders in Congress hammering out a reasonable compromise in spite of that.

But so far, and with time running out on this Congress being able to get something done this year, when year-end must pass pending bills provide a vehicle for passage, old fashioned special interest greed politics still outranks finding a solution for regular people.

I sure hope none of these politicians, more interested in carrying the water for the special interests than worrying about their constituents, don’t need an air ambulance over the holidays.

Robert Laszewski is president, Health Policy and Strategy Associates and blogs at Health Care Policy and Marketplace Review.

Image credit: Shutterstock.com

Prev

A physician's favorite money quotes for the holiday season

December 12, 2019 Kevin 0
…
Next

The indignity of a cancer that takes away bowel functions

December 12, 2019 Kevin 1
…

Tagged as: Public Health & Policy, Washington Watch

Post navigation

< Previous Post
A physician's favorite money quotes for the holiday season
Next Post >
The indignity of a cancer that takes away bowel functions

More by Robert Laszewski

  • Inside the $1.9 trillion coronavirus stimulus bill is a political time bomb for Republicans

    Robert Laszewski
  • What does Kelly Loeffler’s health plan do to coverage for preexisting conditions?

    Robert Laszewski
  • Joe Biden won. What does that mean for health care?

    Robert Laszewski

Related Posts

  • The infiltration of venture capital and private equity in the surprise medical bills debate

    Rachel Bluth and Emmarie Huetteman
  • Digital advances in the medical aid in dying movement

    Jennifer Lynn
  • A surprise pregnancy in medical school

    Christine Loftis
  • How the COVID-19 pandemic highlights the need for social media training in medical education 

    Oscar Chen, Sera Choi, and Clara Seong
  • Why this physician teaches health policy in medical school

    Kenneth Lin, MD
  • Medical trainees need knowledge and education on health care systems and policy

    Daniel Arteaga, MD, MBA and Isobel Rosenthal, MD, MBA

More in Policy

  • Unveiling the global pandemic threat: insights into risk factors and urgent measures for prevention

    Ton La, Jr., MD, JD
  • Why the WHO’s pandemic accord is critical for global health care

    Elizabeth Métraux
  • The revolutionary Kaiser-Geisinger deal: How health care giants are reshaping the industry and empowering patients

    Robert Pearl, MD
  • Unveiling the intricate link between housing costs and health care

    Harvey Castro, MD, MBA
  • Uncovering the truth about racial health inequities in America: a book review

    John Paul Mikhaiel, MD
  • Why affirmative action is crucial for health equity and social justice in medicine

    Katrina Gipson, MD, MPH
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
  • Recent Posts

    • Overcoming the lies of depression: Senator John Fetterman’s struggle with mental health

      Harvey Max Chochinov, MD, PhD | Conditions
    • Master the ABIM Certification exam with effective strategies: insider tips for success

      Farzana Hoque, MD | Education
    • A mentor’s legacy in medicine, leadership, and embracing evidence-based care

      Arthur Lazarus, MD, MBA | Physician
    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
    • Fixing the system and prioritizing patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From medical student to intern: Discovering a deeper connection with patients

      Johnathan Yao, MD, MPH | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 13 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Sickle Cell Disease Poses Major Risk for Pregnant Black Patients
  • CAR-T Tops Standard Care in Heavily Pretreated Lenalidomide-Refractory Myeloma
  • Artificial Intelligence Could Improve Medical Practice -- But Only if Done Right
  • Huntington's Disease Chorea Improved With Valbenazine
  • T-DXd Proves Mettle in Multiple Solid Tumors

Meeting Coverage

  • CAR-T Tops Standard Care in Heavily Pretreated Lenalidomide-Refractory Myeloma
  • T-DXd Proves Mettle in Multiple Solid Tumors
  • Preoperative Ocular Surface Disease Algorithm Re-Introduced
  • Omitting RT Safe in Many Locally Advanced Rectal Cancers
  • Novel IDH1/2 Inhibitor Shows 'Dramatic Effect' in Low-Grade Glioma
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
  • Recent Posts

    • Overcoming the lies of depression: Senator John Fetterman’s struggle with mental health

      Harvey Max Chochinov, MD, PhD | Conditions
    • Master the ABIM Certification exam with effective strategies: insider tips for success

      Farzana Hoque, MD | Education
    • A mentor’s legacy in medicine, leadership, and embracing evidence-based care

      Arthur Lazarus, MD, MBA | Physician
    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
    • Fixing the system and prioritizing patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From medical student to intern: Discovering a deeper connection with patients

      Johnathan Yao, MD, MPH | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Compromise vs. greed in ending surprise medical bills
13 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...