Shrinking networks give rise to surprise medical bills

Person filling out a medical claim form

As insurers pare down provider networks, patients are paying the price in the form of surprise medical bills, a long-standing issue that is prompting more disputes between payers and providers and forcing state legislators to consider additional consumer protections, according to The Wall Street Journal.

Surprise bills often arrive after a patient visits an in-network hospital, but unknowingly receives treatment from an out-of-network specialist--like an anesthesiologist or a radiologist. Insurers cover a portion of the bill, but patients are left to pay the difference--a practice known as “balance billing.”

The rising popularity of narrow network plans--particularly among ACA exchange plans--has exacerbated the issue, and an increasing number of surprise bills have pitted payers and providers against one another. Providers argue that the Affordable Care Act allows insurers to pay less for out-of-network care, while a spokeswoman for America’s Health Insurance Plans tells the WSJ that providers are “essentially demanding a blank check.”

These disputes have prompted several lawsuits. In May, Prime Healthcare sued six insurers, claiming the companies used a “legally inappropriate” system to establish low out-of-network rates, and the American College of Emergency Physicians sued the Obama administration, alleging the president’s landmark healthcare legislation provides no oversight over out-of-network rates for ER doctors.

Emergency physicians have previously warned that a loophole in ACA regulations allows payers to “balance bill” patients for out-of-network services, and pushed for more stringent regulations. Several states, including New York, have implemented their own laws aimed at protecting patients from balance billing.

- read the WSJ article