Balance billing is a matter in which emergency physicians have been placed in an indefensible position. While the underlying causes of balance billing disputes are nuanced and complex, the optics of the matter are inarguable: the physician issuing the bill is universally viewed as the “bad guy.” Bad cases make bad law, and it is the bad cases that make headlines. In New York, a surgeon billed a patient $117,000 for his portion of a spinal surgery.1 Emergency physician bills are far more modest but can still easily reach thousands of dollars when lifesaving services or invasive procedures are performed. Lawmakers, understandably outraged over what they see as abusive practices directed toward vulnerable patients, more and more are turning to outright bans on the practice of balance billing. The issue has even received a media-friendly, scary rebranding as “surprise billing.” Legislation restricting or banning this practice has been proposed or passed in New York, California, Washington, Illinois, Colorado, Florida, and more.
Explore This IssueACEP Now: Vol 34 – No 11 – November 2015
This is a potent threat to emergency physicians; a balance billing ban requires the physician to accept whatever the insurer will pay and no more. This gives the insurer unilateral rate-setting power. Our only negotiating power with carriers comes from the ability to go out of network. When California issued a blanket ban on balance billing, payments to physicians by carriers dropped drastically, by 20 percent overall and up to 33 percent by some payers.2 This revenue loss directly impacts the salaries of emergency physicians.
The hardest thing about losing is to recognize that you are losing. What ACEP, state chapters, and engaged physicians must accept is this: we cannot simply continue to oppose bans on balance billing. If we do, we will lose. Patients are being economically harmed, and though the fault is not ours, the solution must be ours. Emergency physicians are problem solvers by nature. We need to be at the table, proactively, with policy solutions that protect patients while preserving our ability to receive fair payment for services already provided.
The only acceptable solutions are those that will hold the patient harmless and provide a mechanism determining the amount the insurer must pay. With a friendly legislature, one such approach would be to mandate that the carrier must pay the full charges for out-of-network emergency patients. Colorado has passed a law to this effect, and despite fears that it might create an inflationary environment encouraging physicians to raise prices, this has not been observed to date.3