By Antoinette Kraus
About 10 years ago, when a York County girl was just six years old, a school nurse let her family know that she was concerned about the results of some hearing tests she had taken at school.
After a series of appointments, her family found out that she had a serious – and potentially life-threatening – condition of the ears. To save her hearing and reduce the risk of complications, she would need multiple surgeries.
The family’s specialist physician in Pennsylvania advised that they see a specific surgeon in another state who performed these complex procedures regularly for the best chance at a good outcome.
As savvy consumers with a background in the insurance industry, the family knew that they needed to be certain that the surgeon was in their plan’s network, so they checked with both physicians’ offices and were assured that the out-of-state hospital and surgeon were in-network. They chose to move ahead with the surgery, thankful that their plan gave them access to a renowned specialist.
The surgery was successful, but later, the family found out that they had been given bad information, and the hospital where their little girl had surgery was actually considered out-of-network. As a result, they received a surprise medical bill of more than $15,000.
The bill, which came at the same time as an economic downturn, stressed the family’s finances, and eventually led to them filing for medical bankruptcy and closing their small business.
Surprise medical bills like the one this family received are not rare occurrences. Nearly 1 in 3 Pennsylvanians are hit with surprise medical bills in a year. Surprise billing arises when patients are unexpectedly treated by a provider that is not in their insurer’s network.
This often happens when a patient has an emergency and must seek treatment at an out-of-network facility. It can also occur at an in-network hospital when some of the providers who care for a patient are not in the network or when an in-network provider refers a patient to get lab work, a diagnostic test, or other care that is not in the network.
Importantly, a surprise bill is not the fault of a patient, but rather is the result of contracting decisions between insurers and doctors or other healthcare providers. In the case of the family described above, despite having a background in health insurance benefits and his attempts to verify that the physician was in-network, he received a surprise medical bill anyway.
This is typical.
Most patients – who may be facing a medical emergency, illness, or injury or may even be unconscious at the time they received the care — are in no position to figure out whether every single provider they may encounter is in-network.
There is relief on the horizon for patients from these common and unfair bills.
The Surprise Balance Billing Protection Act (HB1862), sponsored by Rep. Tina Pickett, R-Bradford, received unanimous approval in committee, and it’s awaiting a vote on the House floor.
The bill is a bipartisan compromise that protects patients from surprise medical bills such as the one the York County family received while paying providers fairly, maintaining patients’ access to their doctors, and controlling premiums and out-of-pocket costs.
But Pickett’s bill faces opposition.
While everyone agrees that something should be done to protect patients, some provider groups want to replace Pennsylvania’s proposed system for paying providers fairly with a system of arbitration, which would allow providers to dispute any payment made by health plans and do so in a way that could drive up costs.
Repeated studies have shown that relying on arbitration can drive up healthcare costs overall, meaning that patients pay more in the long term for their care.
In New York, where arbitration is used to resolve surprise medical bills, a recent Brookings Institution Report shows that the model has resulted in very high out-of-network payments to providers, which in turn, contributes to higher premiums and out-of-pocket costs for people in that state.
Patients and their families simply can’t wait any longer for relief from these unfair surprise medical bills.
Pickett’s bill protects patients while establishing a fair and transparent process for paying providers and not increasing costs of health coverage. It is poised for passage in the state Legislature.
As lawmakers quickly wind up their work for the year, they need to pass this important patient protection law so there are no longer any surprises for Pennsylvania consumers.
Antoinette Kraus is the executive director of the Pennsylvania Health Access Network, a Philadelphia-based advocacy group.