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.”

Free Daily Newsletter

Like this story? Subscribe to FierceHealthcare!

The healthcare sector remains in flux as policy, regulation, technology and trends shape the market. FierceHealthcare subscribers rely on our suite of newsletters as their must-read source for the latest news, analysis and data impacting their world. Sign up today to get healthcare news and updates delivered to your inbox and read on the go.

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

Suggested Articles

Humana and Microsoft announced a seven-year strategic partnership to build predictive solutions and intelligent automation to support Humana members.

Humana filed suit Friday against more than a dozen generic drugmakers alleging the companies engaged in price fixing.

Nominations are open for our 2020 FierceHealthcare Fierce 15 awards. Think your company has what it takes? Submit your nominations here.