Liam, I agree with your analysis that balance billing, especially when the patient presents to an in-network hospital and is seen by out-of-network emergency and on-call physicians, is ‘an indefensible position’.
The problem with solutions like the one in New York is that it does not eliminate either balance billing or even surprise balance billing, and as such it will continue to generate complaints from patients and resistance from consumer advocates and eventually, calls for regulatory or legislative prohibitions. There should be fewer such surprise balance bills (though the largest bills are the ones that will persist), and this will help, and the law might even encourage plans to offer fair in-network rates. We will have to see how this all plays out in that State, and anywhere else this might be tried.
I will point out, however, that plans are not required to submit all their claims to FAIR Health in the rest of the country, and thus this database is still subject to selective claims submission, which undermined the validity of the Ingenix database. Fair benefits for OON services is a complex issue that is difficult to explain in an elevator speech, and losing this battle may drastically alter the practice of emergency medicine, and undermine access to emergency care for everyone.
Emergency services is an essential health benefit, but is not adequately covered by all health plans. Patient should only be responsible for a deductible when seeking emergency care. Patients should not be placed in a situation wondering how must it will cost for a diagnostic study and refusing necessary emergency care. Health plans should be required to have an adequate emergency provider network and contract with all emergency providers that are in the vicinity of the health plan’s enrollees. Likewise,emergency providers should be required to contract with health plans. Unless a fair payment standard can be established, the best solution is for both parties to negotiate a contract on an even playing field. Patients should not be stuck in the middle.
2 Responses to “Opinion: Emergency Physicians Should Work On Solutions to Balance Billing Issues”
December 7, 2015
Myles Riner, MDLiam, I agree with your analysis that balance billing, especially when the patient presents to an in-network hospital and is seen by out-of-network emergency and on-call physicians, is ‘an indefensible position’.
The problem with solutions like the one in New York is that it does not eliminate either balance billing or even surprise balance billing, and as such it will continue to generate complaints from patients and resistance from consumer advocates and eventually, calls for regulatory or legislative prohibitions. There should be fewer such surprise balance bills (though the largest bills are the ones that will persist), and this will help, and the law might even encourage plans to offer fair in-network rates. We will have to see how this all plays out in that State, and anywhere else this might be tried.
I will point out, however, that plans are not required to submit all their claims to FAIR Health in the rest of the country, and thus this database is still subject to selective claims submission, which undermined the validity of the Ingenix database. Fair benefits for OON services is a complex issue that is difficult to explain in an elevator speech, and losing this battle may drastically alter the practice of emergency medicine, and undermine access to emergency care for everyone.
December 9, 2015
Bing PaoEmergency services is an essential health benefit, but is not adequately covered by all health plans. Patient should only be responsible for a deductible when seeking emergency care. Patients should not be placed in a situation wondering how must it will cost for a diagnostic study and refusing necessary emergency care. Health plans should be required to have an adequate emergency provider network and contract with all emergency providers that are in the vicinity of the health plan’s enrollees. Likewise,emergency providers should be required to contract with health plans. Unless a fair payment standard can be established, the best solution is for both parties to negotiate a contract on an even playing field. Patients should not be stuck in the middle.
Bing Pao