Imagine waking to sharp pain in your abdomen. You rush to the hospital. The doctor diagnosis you with appendicitis, wheels you into surgery, and ultimately saves your life.
Days later, you get a bill — for $5,000. Turns out the hospital, ER doctor, and surgeon were all in your health plan's network — but not the anesthesiologist. So he bills you directly.
Some 60 percent of Americans have been greeted with surprise medical bills like these. Congress should prohibit doctors from sending surprise bills in cases of emergency or involuntary care — and require hospitals and clinics to inform patients whether their doctors are in-network.
Surprise medical bills arrive for many reasons. In straightforward cases, patients receive treatment from providers outside their insurance network, often when they need immediate care.
In other cases, patients may visit an in-network doctor at an in-network hospital only to find out the lab that analyzed their tests was out-of-network. Sometimes, entire departments opt out of otherwise in-network hospitals.
Health plans typically cover a portion of these out-of-network charges. But providers routinely bill patients for the balance — a practice called "balance billing."
Seventy percent of people who have received unaffordable out-of-network bills thought they were using in-network providers, according to the Kaiser Family Foundation.
One study pegged the average out-of-network emergency bill at just over $7,000. Patients were stuck paying 54 percent of that tab, on average — or nearly $3,800.
For specialty care, bills were even higher. That same study determined that out-of-network assistant surgeons, who were often called into surgery without the patient's knowledge, charged an average of nearly $14,000. Over $12,000 of that sum fell to the patient.
Last year, the Virginia Supreme Court sided with a hospital that sued a man over an unpaid $84,000 emergency-room bill. The court ruled the admission paperwork he'd signed in the ER was a valid contract consenting to out-of-network charges.
Most proposed legislative remedies for surprise medical bills would have health plans pick up the balance for out-of-network charges. But to come up with the funds needed to pay out-of-network providers their full fee, health plans would have to raise premiums. Consequently, patients won't be relieved of surprise medical bills; they'd simply pay them in a more roundabout way.
Further, saddling health plans with responsibility for surprise medical bills could encourage providers to opt out of insurance networks and raise their prices.
Providers join networks — and agree to accept discounted payments — to gain access to a health plan's pool of patients. If providers know plans are legally bound to pay them more than the in-network fee, they have little incentive to join — or to lower their prices.
To protect patients, lawmakers must balance responsibility for surprise medical bills between health plans and providers. For example, if there's no opportunity for a patient to switch to an in-network provider, like in an emergency, plans should only have to pay the in-network price.
Such a solution would also benefit the 60 percent of workers whose employers cover their health costs directly through self-funded plans. Organizations that self-insure typically contract with a conventional insurer or third-party administrator to process claims and assemble a provider network. So self-funded employers can similarly be victimized by balance bills.
A medical emergency is surprise enough. A sizable bill from an out-of-network provider shouldn't accompany that surprise. Providers and health plans must share responsibility to ensure that doesn't happen.
Janet Trautwein is CEO of the National Association of Health Underwriters (www.nahu.org). This piece originally ran in the Everett Daily Herald.