04 Oct Surprise Medical Billing
Surprise, surprise, surprise….you just received an unexpected medical bill!
When I first heard the phrase “surprise medical bills” I had no ideas what this was. The term is actually pretty straight forward; a bill you were not expecting. It is also called “balance billing”. The topic has become more publicized recently as Congress, the federal government, and healthcare advocates are beginning to address ever increasing health care costs, including surprise medical bills. The impact of surprise medical billing, which occurs when a patient receives care from a doctor or hospital considered “out of network” from their insurer’s network and subsequently receives a bill much higher than that of an “in network” provider. This commonly happens at hospital emergency rooms.
While this issue is receiving attention, surprise medical billing appears to be increasing, according to JAMA Internal Medicine. The focus by lawmakers and at least one state, California, has not resulted in any consistent plan that is without criticism. California implemented a law (AB 42) that protects patients when they receive care at an in network hospital, but from an out of network provider. The jury is out with regard to the effectiveness of this law. Some research has shown it has helped protect patients from surprise bills, however, other research has shown it impacts provider’s ability to negotiate rates.
Some recent reports have suggested that investors are influencing (and not in a positive way) surprise billing. Kaiser reports that many private physician groups are in fact owned by physicians, but also by savvy investors in private equity and venture capital firms. The business model appears to be in essence surprise billing, which results in much higher profits. There is no unified platform from physicians about surprise medical billing. Many physicians are finding they have little option but to contract with a staffing service that contracts their services out to hospitals. Hospitals then get a share of the profits from the care provided and obviously the most lucrative is out of network care.
A recent expose by CBS news highlighted one case of a man who presented at an emergency room due to a recent MRI showing he had a very serious bulge in his spine. After an MRI he was told to go immediately to the emergency room or he could be paralyzed. Physicians in the emergency room indicated he needed emergency back surgery, which he had. Shortly after he was presented with a $650,000 bill for that surgery; his insurance company indicating the surgery was not medically necessary. This is a clear example of how the average person that may show up at an emergency room is willing to follow the advice of the physicians, without any kind of due diligence with the insurance company, second opinion, etc. But is this not human nature? Imagine going to the emergency room with your young child and you are told that child needs an emergency procedure. My guess is you would likely proceed with little else in mind but your child’s health and wellbeing.
Now that you have a better understanding of what surprise medical billing is, what can you do about it and how can we help? A service we offer is called Quizzify, which focuses on improving health literacy. We know that health literate people have much lower health care costs and are healthier than those who are not health literate. In a recent post by the creator of Quizzify, Al Lewis, he highlights six things employees should know about surprise medical billing. Quizzify is a fun and interactive way for employees to become health literate. If you are interested in learning more, please contact us at the Kansas Business Group on Health.