News 5/10/2019

SHRM: President Trump Urges Congress to End ‘Surprise’ Medical Billing

When they’re having a heart attack, people aren’t likely to ask the ambulance driver if they’re being driven to an emergency room that their health insurance reimburses at in-network rates. When having surgery at an in-network hospital, patients often assume that the surgeon—and the anesthesiologist—must also be in-network. But they may later learn otherwise when they receive an exorbitant bill for these services.

On May 9, President Donald Trump asked lawmakers to prohibit doctors and hospitals from excessively billing patients for the balance not covered by their insurance for emergency treatment at an out-of-network facility or by an out-of-network doctor at an in-network facility.

This must end,” Trump said. “We’re going to hold insurance companies and hospitals accountable.”

Patients “often receive surprise bills at highly inflated prices after receiving care from an out-of-network provider they reasonably assumed was in their network,” according to a White House fact sheet posted the same day. “Patients should not receive surprise bills from out-of-network providers they did not choose.”

Congress is currently considering the following legislation on surprise billing:

“Employers will want to carefully monitor future congressional action in the area of surprise medical billing,” as the legislation could affect the design and cost of employer plans, wrote Lori Jones, chair of law firm Thompson Coburn’s employee benefits practice, in an analysis of these measures.

What Employers Want

Groups representing U.S. employers welcomed the White House announcement, saying they are concerned about the burden that surprise medical bills create for their employees.

“We applaud the president for drawing attention to the hard work already under way by lawmakers in the U.S. Senate Health, Education, Labor and Pensions Committee and elsewhere,” the American Benefits Council, the ERISA Industry Committee and the National Retail Federation said a joint statement. “Employer health plan sponsors share their commitment to ensuring that the more than 181 million Americans who receive health coverage through work are protected from ‘surprise’ medical bills that cannot reasonably be avoided.”

Neil Trautwein, vice president of health care policy for the National Retail Federation, called surprise medical bills “a symptom of high health care costs and out-of-control medical provider fees,” and he urged that out-of-network rates be banned when patients have no control over the emergency facility at which they receive treatment or the out-of-network doctors they may encounter—without being notified—at an in-network facility.

Keeping Network Tiers

Health plans cover a larger share of the cost when employees and covered dependents use in-network doctors and hospitals. Health plans put doctors and hospitals in their networks when they have high-quality ratings and reasonable costs for their services, which the insurer may have negotiated with these providers.

In an April 2 letter to Congress, more than 30 employer groups said that the goal of any federal surprise-billing legislation should be to protect patients who lack a choice of providers, but the groups added that proposed legislation should not discourage plans from incentivizing employees to choose in-network providers when they can do so. The groups advocated legislation that:

  • Requires disclosure of out-of-network professional costs at the time of scheduling to help ensure that patients can make an informed decision and schedule procedures when an in-network professional is available (a provision included in both the Cassidy and Hassan bills).
  • Establishes a federal cap at 125 percent of the Medicare rate for costs associated with having received emergency care at an out-of-network facility, and requires all providers at an in-network facility to accept in-network rates (a provision included in the Hassan bill).

When patients go to an in-network hospital, “they deserve the peace of mind of knowing that every provider they see will accept in-network payment rates,” said James Gelfand, senior vice president for health policy at the ERISA Industry Committee.

What Employers Can Do Now

“Employers need to mine their claims data to determine how widespread an issue surprise billing is for their employees—because it’s going to affect those employees’ financial well-being, stress levels and productivity,” said Kim Buckey, vice president of client services at DirectPath, a benefits education, enrollment and health care transparency firm. “Employers can’t afford the lost productivity related to employees fighting these bills.”

She suggested that employers work with their insurer—or, if self-insured, with their third-party administrator—to educate employees about what to do if they receive an unexpected out-of-network bill. Employers can also help by “having their insurer’s provider-relations department have a conversation with the provider in question [to help negotiate these bills] or agreeing to cover such expenses on the employee’s behalf,” Buckey suggested.

She pointed out that 25 states have some sort of protections in place to curtail surprise billing. However, most large employers are self-insured and regulated by federal law, so “this needs to be addressed at a federal level.” Employers should reach out to their representatives in state and federal government, she advised.


Read the article here.

(Steve covers compensation and benefits for SHRM Online.)

The Strengths and Weaknesses of the Average Consumer’s Health Insurance Understanding
The Strengths and Weaknesses of the Average Consumer’s Health Insurance Understanding
View Infographic