Payer groups, including America's Health Insurance Plans, are joining forces with employers, consumers and other stakeholders in support of a plan they say will tackle surprise billing.
The groups signed on to a set of guiding principles aimed at protecting consumers from the practice. The guidelines are: inform patients when care is out of network, support federal policy that protects consumers while restraining costs and ensuring quality networks and pay out-of-network doctors based on a federal standard.
Meanwhile, the American Hospital Association and the Federation of American Hospitals released a joint statement saying hospitals and health systems also support patient protections from surprise billing but place blame on insurers, not providers.
Surprise billing is a growing problem, especially for people getting emergency room care. A patient may visit an in-network hospital's ER and have no idea that a temporary ER provider is considered out-of-network.
It's a fairly common problem. A recent Kaiser Family Foundation report found that nearly one-fifth of inpatient admissions in large employer health plans include a claim from an out-of-network provider. A different study in Health Affairs found that 20% of all hospital inpatient admissions that originated in the ER resulted in surprise medical bills. About 14% of ER visits and 9% of scheduled inpatient admissions resulted in surprise medical bills.
On Monday, AHIP, the Blue Cross Blue Shield Association, the National Business Group on Health, the National Retail Federation and five other groups released a statement in support of a multi-part plan.
AHIP said surprise billing happens because providers aren't participating in certain networks. "When doctors, hospitals or care specialists choose not to participate in networks — or if they do not meet the standards for inclusion in a network — they charge whatever rates they like," the group wrote.
In their statement, the hospital groups also backed consumer protections, but pointed the finger at payers for the issue. "Inadequate health plan provider networks that limit patient access to emergency care is one of the root causes of surprise bills. Patients should be confident that they can seek immediate lifesaving care at any hospital. The hospital community wants to ensure that patients are protected from surprise gaps in coverage that result in surprise bills, and we look forward to working with policymakers to achieve this goal," they wrote.
The dueling statements come on the heels of a UnitedHealth-Envision contract battle that focuses on out-of-network care and surprise billing. In September, UnitedHealthcare, the nation's largest private payer, threatened to drop Envision after a year of fruitless contract negotiations. The payer blamed Envision, the largest provider of ER doctors, for increasing healthcare costs. The companies announced Tuesday morning they had come to an agreement extending their contract.
Meanwhile, states have done little to protect consumers from surprise billing. A 2017 Altarum report gave only Maine and New Hampshire an A on healthcare price transparency. Maryland and Oregon got a B, Colorado and Virginia received a C and every other state failed.
State regulators have picked up enforcement in out-of-network matters, though. The Texas Department of Insurance recently fined Humana $700,000 for failing to maintain an adequate network of anesthesia services for its plan members in three of the state's largest metropolitan areas.
National leaders have been working on the issue too, but so far a bipartisan effort has only resulted in drafted legislation. The bill would require payers to reimburse out-of-network providers at 125% of the average in-network rate while limiting patient liability to in-network costs.