Surprise medical bills and narrow networks aren’t just a problem for patients, they're a problem for physicians. Now a coalition of doctors is taking aim at the problem and pressing for more states to adopt legislation to solve it.
Physicians for Fair Coverage is a nonprofit, nonpartisan, multispecialty alliance of physician groups that got its start in 2016 and has been advocating to end the surprise insurance gap and improve patient protections. The group includes tens of thousands of emergency physicians, anesthesiologists and radiologists from across the country who each year serve tens of millions of patients.
“We’re really taking on the insurance industry,” Michele H. Kimball, the group’s President and CEO, said in an interview with FierceHealthcare.
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The physicians’ group has taken up the fight as patients’ out-of-pocket medical expenses are increasing and insurance coverage is narrowing.
For some patients, that's resulting in surprise medical bills, created when a patient seeks care at an in-network hospital but is then surprised the doctor treating them is out of their insurance company’s network—a fact they usually find out when they get the doctor’s bill.
It’s a costly and aggravating situation for patients and for doctors who are waiting to get paid.
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A classic example: The insurance company pays the hospital for an emergency room visit, but it doesn’t pay the out-of-network doctor. The patient is responsible for that portion of the bill.
As the American College of Emergency Physicians did last year, the coalition says insurance companies are to blame for the surprise bills, not the doctors who treat these patients.
A solution that benefits doctors, patients
The physician coalition offers a solution to end the coverage gap and reduce, if not eliminate, the need for providers to balance bill patients for the difference between what the patient's health insurance covers and what the provider charges. A preferred provider may not balance bill for covered services, but out-of-network physicians, not bound by contractual, in-network rate agreements, can bill patients for the entire remaining balance.
Emergency doctors, anesthesiologists, radiologists and pathologists are among the specialties most often caught in the out-of-network gap. Many hospitals use physician outsourcing firms for these doctors and in many cases, unknown to patients, these physicians do not participate in the same network as the hospital.
Physicians for Fair Coverage proposes removing patients from insurer-doctor disputes, requiring transparent and predictable pricing between insurers and doctors and creating a minimum standard for reimbursement with penalties for insurers and doctors who don’t comply.
“We have developed a solution based on a set of guidelines supported by all the major medical groups, including the American Medical Association,” says Kimball. The group is also working closely with patient organizations.
The problem, however, has to be solved on a state-by-state basis. Several states have already passed legislation aimed at tackling the problem of surprise bills and the physicians’ coalition has developed model legislation (PDF) based on what was passed in New York and Connecticut that it hopes other states will approve, says Kimball.
An ongoing battle
Just six states offer comprehensive protections from balance billing, according to a report released last year.
In addition to the states with comprehensive protections in place (New York, California, Illinois, Maryland, Florida and Connecticut), 15 states offer partial protections against balance billing, according the Commonwealth Fund. The remaining 29 states and the District of Columbia have no protections.
RELATED: Most states lack strong protections against balance billing
Legislative approaches vary. Some states prohibit providers from balance billing, and others require payers to hold enrollees harmless, often by paying the entire charge. Some states have both rules in place.
New York's law, for instance, protects patients from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills. After completing an "assignment of benefits" form, the provider will pursue payment from the health plan instead of holding the patients responsible.
Additionally, the law sets up an independent dispute resolution process for health insurers and providers to use to settle on a fee for surprise bills.
Connecticut requires the use of an independent and transparent charge database to determine reimbursement for emergency services received out of network.
With legislative sessions across the country picking up in the new year, there are many bills being introduced in different states to address surprise medical billing and balance billing from both sides of the issue—doctors and insurance companies. Kimball says it is important that states ensure that doctors receive a “fair and reasonable” rate from insurers.
RELATED: Efficient, fair payer-provider negotiations first step in solving surprise bills
Physicians for Fair Coverage says there should be an appropriate and fair standard for out-of-network services using a reimbursement schedule connected to an independently recognized and verified charge-based database. It recommends that FAIR Health, which it says maintains the largest collection of private insurance claims in the United States, be used to benchmark physician fees.
The coalition supports legislative efforts that would require the following:
- A minimum benefit standard for out-of-network care with transparent, predictable and fair pricing for medical services so patients aren’t surprised about their health insurance coverage.
- An adequate number of doctors and clinicians in health plan networks, especially in the emergency department, to serve the number of patients in that network.
- In-network rates for patients who encounter unexpected out-of-network care.
- Protections for patients so they are removed from payment disputes between clinicians and insurance companies.
- A mediation process that a patient or clinician can initiate with resolution within 30 days.
- Requirements to prevent insurers from providing false, misleading or confusing information.
- Strong penalties for insurers and clinicians who violate the patient coverage protections in the law.
Changes should also protect patients’ access to care in rural areas or in small communities, which may have limited in-network specialists, Kimball said.