Ending Surprise Medical Billing

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I remember how terrifying it was to hear the diagnosis of breast cancer. At the age of 35, I had to face a potentially life-threatening diagnosis, major surgery and chemotherapy after that.

If that wasn’t enough, what if I had woken up after my mastectomy only to discover that I had a bill for thousands of dollars that my insurance wouldn’t cover and I couldn’t pay?

Many women today are facing that very situation.

A recent study by Kaiser Family Foundation found that 21% of women who had a mastectomy at an in-network facility received bills for out-of-network charges. Such charges may be only one piece of the large financial burden, often referred to as “financial toxicity”, that a breast cancer patient faces.

What is Surprise Billing?

The problem of surprise medical billing, also sometimes called “balance billing”, has been around for a while. Until relatively recently, the problem was most often connected with emergency surgery. But new studies are showing it now happens with non-emergency or elective surgeries as well.

The basic scenario is this. You’ve found you need surgery. Fortunately, you have (you think) good health insurance, but you know you need to choose providers that are in your insurance network. So, you do your homework and make sure to select both a hospital and a surgeon that are in your network.

So far so good. But as this scenario plays out you eventually receive a huge bill from, let’s say, an anesthesiologist who treated you during your surgery. Or it could be from a radiologist or a pathologist who was involved in your care. We as patients normally have no involvement in the choice of these providers when we’re having surgery.

If the anesthesiologist were in your insurance network, their bill would be discounted to begin with, and your insurance would pay most of it, typically leaving you with a reasonable amount for your out-of-pocket expense. But if they’re not in your insurance network, there’s no discount, your insurance company may pay a small out-0f-network amount, and you’re left with the entire “balance”! Hence the term, balance billing.

How Many Are Affected?

How widespread is the problem of surprise medical billing?

The Kaiser Family Foundation estimates that about 18% of emergency visits and 16% of admissions at an in-network hospital lead to at least one out-of-network charge.

Another recent study published in JAMA looked specifically at elective surgery at in-network hospitals. This study found that about 20% of the time patients having elective surgery at in-network hospitals receive surprise bills from out-of-network providers and that the average amount of the bill is about $2,000.

Ending Surprise Billing

So, what is the solution to this problem? It is simply this: take the patient “out of the middle”. You the patient pay what you normally would out-of-pocket for the medical services you received. Separate protocols are established that govern what payment the provider will receive from your insurance company.

In the absence of federal legislation, a number of states have tackled this problem with varying legislative fixes. Here in Virginia, there’s a bill before the General Assembly right now.

However, the best solution would be a federal law to deal with this problem more comprehensively than state laws, which are inconsistent and don’t cover all types of plans. Eight in ten Americans support passage of federal legislation to protect patients from surprise medical bills. There are bills currently before both houses of Congress that would protect consumers from surprise medical bills and the bills are supported by both Democrats and Republicans.

Surprise billing is only one piece of the financial toxicity that cancer patients face. Much bigger solutions are desperately needed. But this particular problem has a fairly straightforward answer. Let’s fix this one now. Please call your elected representatives and let them know you want legislation passed to end surprise medical billing.

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Image Credit: zimmytws via Shutterstock

5 comments

  1. We have some great protections here in Florida but I still get bills that should never be sent. I report every company who does it because I know others who don’t know often pay bills they don’t own. I think when you are already dying to try to squeeze more $$ out of people already struggling should be criminal. Just my two cents.

    1. So you’re receiving bills that are not allowable under current laws in your state? Are you getting any response when you report this? I suppose it’s a good thing that you know to watch out for this but it’s not something you or anyone else should have to try to protect themselves against.

      1. Oh yes, I get bills that are flat out illegal. The companies’ are fined for violations and they just keep on doing it. I’ve asked for investigations to be opened but nothing has happened yet.

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