U.S. advances key new protections for patients from ‘surprise’ medical bills

billsmedical1-300x200Federal regulators have taken a welcome initial step to bar insurers and health care providers from holding patients hostage in their all-too-common fee fights, with draft rules out now to crush “surprise” medical bills.

The politically riven, do-nothing Congress shocked critics by ending 2020 with an actual new law, included in legislation dealing with the coronavirus pandemic, that gave patients new protection from nightmares created when insurers and big corporation sought to reduce their health care costs with so-called narrow networks of pre-approved health care providers.

This scheme allowed insurers and companies to negotiate with doctors, labs, hospitals, and others for preferential prices, and, effectively, guarantees of patient business, in exchange. Patients began howling when their long-time caregivers were excluded from insurer networks, which also often also excluded big-name practitioners as well as well-known academic medical centers and big hospitals.

The new procedures also suddenly meant that patients were hit with whopping bills from “out-of-network providers.”

These might be specialists called in for consultations while patients experienced medical emergencies or even may have been under anesthesia. They also included shocking up-charges by: pathologists and their labs; emergency room experts; anesthesiologists; and by surgeons conducting the equivalent of medical drive-bys. Emergency transport, especially by air ambulance, became so pricey that it seemed as if patients needed to keep stacks of gold bars by their sides.

Providers argued that they were giving needed care and that they and patients should not be shut out or penalized by insurer and corporate deal-making. Journalists and news organizations reported billing outrage after outrage, as patient complaints hit a crescendo. Congress acted, leaving it to the giant Health and Human Services agency to determine the best regulations to clean up the mess. As the Washington Post reported of the initial agency rules:

“[The regulations] spell out that, if a health plan provides for any emergency services, those services must be covered without requiring permission from an insurer ahead of time. And no matter whether the emergency room or its doctors are part of the insurer’s network, patients may not be charged more for emergency care or air ambulances than if those services were given by providers in the insurer’s network. Patients cannot be billed, in other words, for the difference between what the hospital charges and what an insurance company pays for out-of-network care. Another aspect of the rules bans higher charges in instances in which an anesthesiologist, assistant surgeon, or others providing such ancillary care are outside of a network even though the patient’s main surgeon is part of a health plan’s network of allowed medical personnel and facilities.”

The newspaper emphasized how big a menace surprise billing had become for U.S. patients, reporting:

“About two-thirds of U.S. adults said they were very or somewhat worried about being able to afford large bills from a health-care provider outside their insurance network, according to polling earlier this year by the Kaiser Family Foundation, a health-care policy group. Worry about such bills exceeds concerns about affording prescription drugs or other parts of their health insurance, such as deductibles or monthly premiums, Kaiser’s survey shows. Other Kaiser data, published last year in the Journal of the American Medical Association, shows that 1 in 5 insured adults had received an unexpectedly high medical bill from an out-of-network provider of care in the previous two years. A 2019 study by the federal Government Accountability Office found that about 7 in 10 trips by air ambulances — conveying to hospitals seriously ill patients who seldom choose which company to call — were outside the patients’ insurance networks. Typical prices for a trip were $36,000 to $40,000, according to data the study examined.”

Regulators, in the 60-day public comment period on their new rules, will be barraged by lobbyists and others pushing the views of insurers, big corporations, and various health providers. They also will struggle to figure technical issues that patients — we hope — could care less about but which will be huge for those in the business of medicine: The who and how of resolving fee disputes now that patients can’t get socked with them. But the parties involved long have slammed patients with a forced arbitration, the system they now must work within, so good luck to them.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, excellent, and efficient medical care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.

Alas, while modern medicine may make terrific advances in treatment, a major and infuriating aspect of health care punches patients in the face — the antiquarian, relentless, and murky billing practices of providers. Who can make any sense of the mass of bumpf that flies between insurers and practitioners, with frustrated patients stuck in the morass — including with cryptic procedure codes and inexplicable surprise charges?

Is it surprising, then, that another 2020 effort on making medical economics more transparent is struggling? Hospitals, which have become a leading driver of U.S. health care costs, keep dragging their feet on providing the swift, easy, and convenient online posting of information on deals they have cut on prices for hundreds of their most common procedures and items. The Trump Administration imposed regulations on the institutions requiring this disclosure. If it’s happening, it’s going slowly and without the public oomph that reformers wanted. Sigh.

We have much work to do still to slash unreasonable medical costs and to ensure that health care expenses are fair, affordable, and comprehensible.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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