Lawmakers in Washington D.C. are heading back to the table, looking to provide consumers with some additional resources and protections from "surprise medical bills." But emergency service industries say the proposals could leave them grounded.
The Lower Health Care Costs Act seeks to address the practice of ‘surprise billing,’ when patients are faced with costly medical bills after unintentionally receiving care from an out-of-network provider.
Several instances of surprise medical bills have gained national attention, especially when patients find that treatment at an in-network hospital is accompanied by an out-of-network service like an anesthesiologist or others.
The Lower Health Care Costs Act reportedly passed out of the Senate HELP Committee by a wide bipartisan margin.
Also, the House companion to the legislation could potentially include language that would prohibit certain services, like air ambulances, from practicing so-called "balance billing," in which patients are billed for the remaining total after an insurance company pays a portion of a bill to an out-of-network provider.
Katherine Hempstead, the senior policy adviser at the Robert Wood Johnson Foundation, says it's a practice that stems from the insurance providers and service providers being at odds.
"So some of that fee is covered by the insurance company, but the provider really isn't in-network with the insurance companies, and so then the provider tries to go and get the rest of their fee from the patient," Hempstead explains.
In some cases, those balances can be thousands of dollars.
"I think it comes up in those situations where people have the least choice, and they're most likely to say, 'Oh, thank God I had insurance, so all of that is taken care of blah blah blah', and then the next thing you know you're in collections for what can often be a really really big bill," Hempstead said.
But some industries, like the air ambulance industry, says the ability to "balance bill" is what keeps them off the ground.
"We've already seen 32 bases close this year in the U.S.," said Seth Myers, the President of Air Evac Lifeteam, an air ambulance company. "If this bill were enacted the way it is written, hundreds of bases would close."
Myers explains that from an industry standpoint, balance bills are used to help offset the cost of treatment for those with Medicaid or Medicare.
"Seventy percent, actually a little more than 70 percent, of the people that we fly that are covered by Medicare, Medicaid, or no have insurance, don't pay anywhere close to our actual cost to provide the flight and so we rely on that cost shift over to commercial insurance," he said.
According to Myers, only about seven percent of all Air Evac Lifeteam patients are even eligible to be balance billed.
Myers also said that new research from Wyoming shows that the average consumer pays about $700 for an amount that is balance billed, even if the bill is for higher.
But Hempstead said even that number should require a second look.
"It feels like every month there's a new study that the average American family can't afford an unexpected $400 expense," she said.
Combining an air ambulance service with costs that are also likely accrued at hospitals or during life-saving treatment can add up to a tremendous burden on families, said Hempstead.
But whether a "balance billing ban" will leave patients without access to air ambulance services remains to be seen.
Hempstead said it's a common practice of providers to threaten the inability to serve people if they can't bill what they feel is appropriate.
But for the air ambulance companies, they say the more then 550,000 patients who ride in their helicopters annually could be left without service if they can't afford to fly.
Myers said that impact could be disproportionately rural.
"Of our patients, 90 percent are coming from a rural or super rural zip code," he said.
According to Myers, 20 percent of the nation's population, living on 80% of the land (mostly rural) accounts for the majority of the air transportations that happen.
Myers said that the evidence suggests that rural patients are more likely to have Medicaid or Medicare, and are more likely to need air ambulance services for issues like strokes and traffic crashes.
Hempstead said that while there may be discrepancies in how insurance companies and service providers are looking to handle surprise medical bills and balance billing, she feels that many of them are looking for a solution.
"I think most of the healthcare industry just wants this to end," she said. "Because it really is a bad look for them and it's eroding trust."
While surprise medical bills are nothing new, Hempstead says the fact that they are gaining national attention points to the shifting attitudes on healthcare in the country.
"The combination of regulators, insurers, and providers, they're sort of going to have to be able to come together and show that they can come up with a reasonably equitable solution to this that improves things for patients, and keeps access to care, and sort of keeps us out of drama and chaos," she explained.
Discussions on balance billing and surprise medical bills could be just the tip of the iceberg.
"When you look at all the talk of single-payer healthcare systems, the providers and the insurance companies know they're looking at needing to find a solution before it gets to that," she explained.
As for air ambulance providers, Myers says they feel that if anything is going to be done on a national level, it needs to be done through a committee that was created on November 2018 to analyze the data and facts around air ambulance costs specifically.
Also, Myers says they would like to see reforms on how insurance companies are allowed to handle air ambulance services.
"Require insurance companies in-network because many states have no in-network air providers and insurance providers should have an in-network provider for those they cover," he said.
In Ohio, Myers says companies have to independently negotiate with insurance companies to make sure their services are covered at all.
In addition to the Lower Health Care Costs Act, several other possibilities have been introduced to lawmakers that could potentially stop surprise bills and balanced billing.
Ohio Senator Sherrod Brown joined Republican Senator Bill Cassidy and a bipartisan group of Senators to introduce the STOP Surprise Medical Bills Act.
Brown said in a release that his priority is to help the patients and consumers of Ohio who may be faced with these bills.
“When it comes to surprise medical bills, we should always be putting the patient first. Ohioans shouldn’t have to worry about the cost of an out-of-network hospital bill or an air ambulance ride when they’re facing a medical emergency. Addressing surprise medical bills is a bipartisan issue, and I will continue standing with Ohio patients and families," Senator Brown said.
The STOP Surprise Medical Bills Act addresses three scenarios in which surprise medical billing (also known as “balance billing”) would be prohibited:
· Emergency services: The bill would ensure that a patient is only required to pay the in-network cost-sharing amount required by their health plan for emergency services, regardless of them being treated at an out-of-network facility or by an out-of-network provider.
· Non-Emergency services following an emergency service at an out-of-network facility: This bill would protect patients who require additional health care services after receiving emergency care at an out-of-network facility, but cannot be moved without medical transport from the out-of-network facility.
· Non-Emergency services performed by an out-of-network provider at an in-network facility: The bill would ensure that patients owe no more than their in-network cost-sharing in the case of a non-emergency service that is provided by an out-of-network provider at an in-network facility. Further, patients could not receive a surprise medical bill for services that are ordered by an in-network provider at a provider’s office but are provided by an out-of-network provider, such as an out-of-network laboratory or imaging services.
Under that bill, providers would automatically be paid the difference between the patient’s in-network cost-sharing amount and the median in-network rate for these services, but providers and plans would have the opportunity to appeal this payment amount through an independent dispute resolution process, should they see fit.
This “baseball-style” arbitration process would entail the plan and provider submitting offers to an independent dispute resolution entity that has been certified by the Secretaries of HHS and the Department of Labor.
This entity would make a final decision based upon specific factors, including the commercially-reasonable rates for that geographic area.