Going to the emergency room or needing hospital care is stressful enough for patients and their families. This challenging time shouldn't be exacerbated by the financial hardships inflicted by a "surprise medical bill."
As the name suggests, this byproduct of the American health system's complexity occurs when patients are saddled with unexpectedly large out-of-pocket costs for care they thought would be covered by insurance. A too-common scenario: A patient goes to a hospital within their insurer's network, but gets care there from a higher cost out-of-network emergency room physician, anesthesiologist or other specialist.
Surprise bills are hard to avoid, with 18% of emergency room visits nationally resulting in at least one such charge, according to a recent Peterson-Kaiser Family Foundation (KFF) report. Fortunately, that will change in about a year. Strong, sensible reforms to help prevent surprise medical bills were included in the massive end-of-year funding and relief bill Congress just passed. The changes go into effect in 2022.
The reforms, which have been under discussion for years, are overdue but nevertheless a valuable reminder that bipartisanship is possible and produces good policy. Champions of change included Minnesota Democratic Sens. Tina Smith and Amy Klobuchar and Republican Sens. Bill Cassidy of Louisiana and Lamar Alexander of Tennessee.
"Putting an end to surprise medical bills for patients in Minnesota and across the country has been a priority for me for years," said Smith, a member of the Senate Committee on Health, Education, Labor and Pensions. "Getting it done at the end of such a difficult year — with bipartisan support in Congress — is an important sign that Democrats and Republicans can find common ground to improve people's lives as we move into the new year."
The reforms truly represent significant new consumer protections. While some states, including Minnesota, have enacted some billing changes, nationwide safeguards are needed. In addition, many people get their coverage from employer plans which tend to be regulated at the federal level.
What's also admirable is that lawmakers upset the surprise-bill status quo that worked well for medical providers, insurers and Wall Street. Large, private-equity groups are among those profiting from surprise billing because they own large physician or emergency staffing companies. The physicians are out-of-network, a status that allows for higher charges. Financiers have turned this into a bankable industry niche.
When patients ultimately got stuck with the bill, there was little reason for the health care industry to seek change. That the congressional reforms put patients first over wealthy special interests is indeed commendable.
The changes should prevent most stomach-churning episodes of opening up a medical bill and seeing an unexpected big-dollar charge labeled "Patient Responsibility."
"These are the kinds of surprise bills that will be prohibited: You go to an ER and the hospital or doctors bill you over and above what your insurance pays," KFF expert Larry Levitt recently tweeted. "You go to an in-network hospital and an out-of-network doctor treating you bills you extra."
At the same time, Levitt cautioned, patients will still be responsible in 2022 for the charges that normally incurred when they seek care from in-network facilities or specialists. The reforms don't wave away standard deductible or cost-sharing responsibilities.
The surprise-bill reforms are also another reason to buy a health plan that complies with Affordable Care Act requirements. The new protections don't apply to so-called "short-term plans," according to Levitt. It's yet another reason to steer clear of this skimpy, deceptively cheap coverage option.