..we met the surgeon as I was being..taken into the operating room… the surgeon’s bill $17,000.. I called the insurance company..”Sorry, he’s not one of ours. No contract with us.”

“About a year ago, I began to have stomach discomfort and thought I had overdone it at Starbucks. The pain got worse overnight. Antacids didn’t help. Then came the nausea, 102-degree fever and pain that had moved to my lower right side, making it difficult to lift my leg. By dawn, I knew it was appendicitis and told my husband we had to go to the hospital… Then we met the surgeon as I was being prepared to be taken into the operating room. He explained that if he didn’t operate right away, I might get sepsis and die. He also said he didn’t take my insurance but assured us I was in capable hands, as he was very experienced. After asking about our occupations, he announced his fee for my laparoscopic appendectomy would be $15,000. We were stunned by the timing and the amount. Was this supposed to be a negotiation?” Eventually, the surgeon’s bill arrived: $17,000 including charges for an ER consult neither my husband nor I recall. I called the insurance company (for which we’re paying more than $25,000 in annual premiums). Sorry, he’s not one of ours. No contract with us.” (U)

The House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions Committee reached a deal last year that uses a benchmark rate and an arbitration backstop for any charges above $750. But the House Ways and Means Committee announced shortly thereafter they are working on their own legislation that may be more provider-friendly…

House Majority Leader Steny Hoyer told reporters last week that he is turning to the committee chairmen to settle any dispute, according to a report in The Hill newspaper. Energy and Commerce Committee Chairman Rep. Frank Pallone, D-New Jersey, calls tackling “devastating” surprise medical bills one of his top priorities, a committee spokesperson said.” (V)


PARTS 1-4. SURPRISE MEDICAL BILLS. “I was never in a position to preselect who (would) perform my heart transplant,” (and if the physicians and surgeons were in network)….because I did not know when a new heart would become available.

ASSIGNMENT: after doing a comprehensive analysis of current state Surprise Billing legislation, prepare a model state bill.

“A woman from New York City received an eye-widening check after visiting a doctor for her strep throat. She had to pay more than $28,000 after taking simple tests that involved only a swab, taking blood samples and antibiotics…

Kasdan told “Bill of the Month,” a joint project between NPR and Kaiser Health News, that she received the bill worth $28,395.50 in October. Her health insurance company gave her a check for $25,865.24…

Her strep throat checkup grew to the eye-popping amount because both the clinic and laboratory that conducted the tests were out of network. The lab also appeared with the same phone number and address as the doctor’s office Kasdan visited.

A $25,000 bill should be surprising for a strep throat test. An in-network throat swab and tests commonly cost only nearly $600, while an average co-pay for a specialist ranges from $30 to $50, MarketWatch reported Wednesday.” (A)

“People who are in the middle of a health crisis often are at an especially high risk for surprise medical bills, according to previously unreleased data from the Kaiser Family Foundation.

The big picture: The new data underscore the importance of a legislative solution to help patients who are powerless to protect themselves.

Details: People having surgery or receiving mental health and substance abuse treatment at an in-network hospital are the most likely to experience a surprise bill from an out-of-network provider.

Among people with employer-based insurance, out-of-network charges were 50% higher among heart-attack victims than for other diagnoses…

Half of the American people say they would have to borrow money or go into debt to pay a $500 medical bill, or wouldn’t be able to pay it at all.

Unexpected medical bills are the public’s top health cost concern, ahead of deductibles, premiums, drug costs, and even paying the rent or the mortgage.

People with major medical conditions and chronic illnesses are most likely to experience problems paying their medical bills.

The bottom line: Congress is torn between two competing ideas solving this issue and settling payment disputes between insurers and providers. Each plan has its own implications for premiums and industry negotiations, but for patients, just getting a fix is the most important thing.” (B)

“Emergency medicine specialists were most likely to generate “surprise bills,” or out-of-network bills for services provided at in-network facilities, compared to six other specialties, according to an analysis by the Health Care Cost Institute, an independent, nonprofit research organization.

The analysis is based on national claims data for patients with employer-sponsored insurance in 2017. Claims for anesthesia, behavioral health, cardiovascular, emergency, pathology, radiology and surgery services were included. HCCI grouped claims into “visits” by compiling claims by individual patient, type of service and day, and then examined how many of those visits involved out-of-network claims.

How the seven specialties compare:

Emergency medicine specialists — 16.5 percent of emergency visits resulted in a surprise bill from an emergency medicine specialist

Pathologists — 12.9 percent

Anesthesiologists — 8.3 percent

Behavioral health provider — 6.7 percent

Radiologist — 4.2 percent

Surgeon — 2.1 percent

Cardiovascular specialists — 2 percent (C)

“Heart attack patients may be more at risk of surprise medical bills

We examined the incidence of out-of-network charges among people covered by large employer health plans who received emergency services or inpatient stays at in-network facilities for a heart attack. The incidence of out-of-network charges was 50% higher for heart attacks compared to the incidence rate of all diagnoses for both emergency services (27% vs. 18%) and for inpatient admission at in-network facilities (23% vs. 16%), respectively…

While potential surprise bills are relatively common, in general, patients with serious or complex conditions may be even more likely to face such charges, depending on the types of services they need and providers they encounter. As this analysis shows, admissions at in-network hospitals for maternity and newborn led to an out-of-network bill about 10% of the time, compared to almost a quarter of admissions involving a heart attack. The higher likelihood of surprise out-of-network medical bills, in turn, increases a patient’s financial exposure. While a person giving birth usually has more time to prepare and presumably plan for in-network provider use than a person having a heart attack would, one in ten maternity-related admissions at in-network hospitals still led to an out-of-network charge. The nature of surprise medical bills is that they cannot be reasonably prevented through planning.” (D)

“Texas will soon enact a law to prevent patients from getting hit with surprise medical bills.

It appears Texas will get one of the strongest laws in the nation against surprise medical bills after all.

Earlier this year, lawmakers passed legislation to protect people in state-regulated health plans from getting outrageous bills for out-of-network care.

The law, which takes effect Jan. 1, wavered last month when the Texas Medical Board drafted the rules for its implementation. The board, made up of health care providers, tried to get a blanket exception to the law for virtually all nonemergency cases.

Instead, after an outcry from advocates and media coverage by KUT, NPR and Kaiser Health News, the board decided to relinquish its rule-making authority.

The Texas Department of Insurance instead took over writing the rules that health care providers will have to follow. On Wednesday, the agency released a set of rules that advocates say are good for patients…

At issue is a piece of the law meant to allow patients to freely choose a doctor out of their insurance networks when they wish. In those cases, patients can sign a form saying they realize they may have to pay more for out-of-network care. The medical board tried to interpret that part of the law broadly, so that every patient would sign such a form before any nonemergency procedure…

Senate Bill 1264 creates an arbitration process for insurers and providers to negotiate fair prices for that out-of-network care without involving patients. Currently, patients can get a “surprise bill” when both sides can’t agree on a fair price…

Jamie Dudensing, the CEO of the Texas Association of Health Plans, said the state insurance agency’s new rules “correctly implement the consumer protections in Senate Bill 1264 and ensure Texas patients no longer have to worry about surprise billing.” “(E)

“After months of hearings and negotiations, millions of dollars in attack ads, full-court-press lobbying efforts and countless rounds of negotiations, Congress appears to be moving toward a solution to the nation’s surprise medical bill problem. Sort of…

Two committees, the Senate Health, Education, Labor and Pensions Committee and the House Energy and Commerce Committee, have been working on plans and announced a compromise Dec. 8. Later that week, the House Ways and Means Committee followed suit by announcing its solution, though details are few…

Despite the rushed way some committee members announced the agreement Dec. 8 — issuing a press release on a Sunday before any official bill text was released — it’s now looking unlikely that Congress will consider the package before it wraps up work for the year…

Over the past few months, the biggest debate around remedies for surprise bills has centered on how to determine payment for out-of-network doctors and hospitals. One group wanted an arbitration process while the other sought a benchmark system. It seems neither side will get exactly what it was seeking.

Under benchmarking, the government would set a compensation rate for providers when they see out-of-network patients. The most popular proposition was one that paid a “median in-network” rate, where doctors are paid in the middle of the range of what others in the area are paid by insurance companies for the same service.

The other idea was independent dispute resolution, or arbitration. The provider and insurer bring their best offer to a third party, who chooses between the two…

Generally, employers and consumer advocates favor benchmarking. Hospitals and doctors’ groups — especially those backed by private equity firms — pushed for arbitration.

Political muscle could also factor into the measure’s momentum.

Money from private equity has been flowing into the debate, from millions of dollars spent on commercials and online ads to campaign donations… “(F)

“The House Ways and Means Committee released its own proposal Wednesday for ending surprise medical bills, potentially complicating an effort by some lawmakers to include a rival proposal in a year-end spending bill…

The Ways and Means Committee plan appears to resolve payment disputes by allowing health care providers and insurers to enter into arbitration, a method favored by hospitals and most doctors’ groups. The committee’s leaders called on lawmakers to slow down the process, while the leaders of the House Energy and Commerce Committee have been pushing for action within the next two weeks.

“There are multiple good-faith proposals from other Committees, but given our jurisdiction, it is crucial that we get this right,” Ways and Means Chairman Richard E. Neal, D-Mass., and ranking member Rep. Kevin Brady, R-Texas, said in a joint statement. “The House, Senate, and Administration all need to stay at the table and debate these ideas as we decide the best, most patient-focused path forward. We look forward to working together with our Committee Members and having this be one of the first things we consider in the new year.”…

So far, no top party leader in either chamber has endorsed the House-Senate committee deal, which several lawmakers have said is holding up movement on the agreement. Senate Minority Leader Charles E. Schumer, D-N.Y., said in response to a CQ Roll Call question Tuesday that there were “many disagreements” on the policy, although he also said, “We have to do something about surprise billing.” (G)

“Doctors and the private equity firms behind them can reap huge extra profits by charging patients essentially whatever they decide the price should be. The practice raises insurance costs for everyone….

Opinions vary on what happened. Some think it may have just been jurisdictional jostling, whereas Republicans suspect Neal was working with Democratic leadership to deliberately tank a solution. Of particular frustration is that Neal’s counterproposal wasn’t even a piece of legislation but only a vague one-page outline.

When asked by BuzzFeed News, Neal conceded his proposal does not answer the key question of how much to pay for out-of-network emergency room procedures after surprise billing is banned. “We have not fleshed that out, no,” he said. Neal previously proposed a bill that did not contain a solution at all. Instead, it would have kicked the matter to the Trump White House to solve.

But Neal insists he is committed to ending surprise medical billing. He said the House–Senate compromise was rushed and there was not enough time to scrutinize it between impeachment, the USMCA trade deal, and other pressing issues.

“We didn’t have time to review it. There was no time to review it because of the way that it was mustered,” said Neal. He said that any solution needs to hold up under the scrutiny of a magnifying glass and that’s what he intends to work on next year.” (H)

“This is what makes surprise billing so uniquely Kafkaesque, even among the many horrors of the American medical system: The bills victimize people who do everything right. You can pay for insurance, pick a doctor carefully, make sure the hospital where you have scheduled your procedure takes your coverage, and still end up on the hook for more than $100,000 because an assistant surgeon who didn’t accept your insurance swooped in to the operating room while you were unconscious. True story.

The sheer unfairness of it all, and bipartisan voter support for fixing it (78 percent of Americans have said they would like to see a federal bill) is why both Democrats and Republicans basically agree that something needs to be done. Moreover, it’s an issue that only Washington can fix. States have taken steps to protect some of their residents from surprise bills but can’t fully address the issue because of a federal law that prevents them from regulating most large employer-based health plans. If Congress doesn’t act, nobody can…

But beyond the tough optics of taking on the doctor lobby, this also seems like a story about the power of donors over some influential Democrats—particularly Neal, the Ways and Means chairman. Health care providers have long been some of his largest donors, which is unsurprising, since his committee has jurisdiction over Medicare. This year, however, he received a $29,000 donation from the Blackstone Group, the private equity giant that owns TeamHealth, one of the country’s largest physician staffing firms, which stood to lose out from Congress’ compromise bill. As Kaiser Health News reporter Rachel Bluth notes, this was the first year Blackstone showed up in Neal’s top five donors.” (I)

“Here are some other reasons you might receive a shock bill:

Out-of-pocket costs. How surprised you are by the size of a medical bill may be a function of how well you understand the cost-sharing terms of your insurance policy, such as the deductible, copays and coinsurance. Experts estimate that one-fourth of Americans who carry health insurance are actually underinsured because of coverage gaps and out-of-pocket expenses, according to a 2019 Commonwealth Fund report…

Billing errors. Every medical procedure has a five-digit Current Procedural Terminology (CPT) code, which providers list on bills and insurance claims. (Medicare has a similar system called the Healthcare Common Procedure Coding System, or HCPCS.) With thousands of codes, and paperwork that goes through multiple hands, “human error happens, both in inputting those codes and in accepting them as accurate,” says Caroline Pearson, a health policy expert at NORC, a research institution at the University of Chicago.

The more complex the bill, the more likely it is to include mistakes. A surgery or hospitalization can involve dozens of services, medications and consultations. That’s dozens of opportunities for typos, clerical errors and confusion between what a doctor ordered and what was actually done, says Victoria Caras, the owner of Aspen Medical Billing Advocates, a Colorado firm that works with patients to review and reduce health care bills…

Billing fraud. Most medical billing errors are just that — errors. But outright phony charging does occur. According to the National Health Care Anti-Fraud Association and billing experts, common types of billing fraud include:

Billing for procedures or services that were not performed, or that were performed but were not medically necessary.

Double billing for a procedure that was done once.

Billing for a more expensive service than was performed, a practice known as “upcoding.” For example, tests done by technicians could be coded as being done by physicians.

“Unbundling” — boosting charges by billing individually for related services that are commonly billed with a single code, such as cleaning, stitching and dressing a wound.

Billing a patient for more than the copay amount…”  (J)

“Given the market failures and consumer expectations at the heart of surprise billing, it is no surprise that there is pressure for the government to intervene. Currently there’s no federal law to protect consumers from receiving a surprise bill. There are some state laws, tracked by Kevin Lucia and Jack Hoadley of Georgetown University’s Health Policy Institute for the Commonwealth Fund. But even the states that have acted are preempted by federal law from protecting consumers who get their insurance from employers with self-funded plans.

Solutions at the state level fall into two categories. States may set a reimbursement rate for out-of-network services received at an in-network facility — for example, tying them to Medicare rates so the consumer doesn’t receive an astronomically high bill. The other is establishing an arbitration procedure that determines how a dispute between insurers, providers, and consumers should be resolved.

To avoid accusations of price-setting, policymakers have shied away from the first approach and leaned toward the second. Although arbitration is a form of regulation, it doesn’t cause opponents as much aggravation: the government is determining the process of rate-setting rather than the rate itself. But even establishing a process is a step away from free markets…

As policymakers search for a solution, they should consider that regulation that either prevents providers from balance billing or holds the consumer harmless — that is, protects them from paying the surprise bill by leaving it to the insurers and providers to fight it out — would help address the public sense of injustice around these bills. Many state laws do this. But without price regulation to take market power away from local providers, the surprise billing problem won’t go away.” (K)

“The fall issue of Regulation includes two articles on surprise billing that propose different solutions. One endorses mandatory arbitration of surprise charges as the most neutral market-oriented solution. Unlike the dropped provision, this solution would not impose a rate for physicians’ services. Instead, in cases in which in-network reimbursement rates differed from out-of-network provider charges, patients would be responsible only for the usual in-network charge and the decision over whether the provider payment request or the insurer network reimbursement would prevail would be made by an independent arbitrator.

A second recommends a contract-based alternative in which in-network hospitals become responsible for resolving surprise billing by providers who work at the hospitals. This solution would require all providers at a hospital to contract with the same insurers as the hospital or to secure payment for their services from the hospital, which would bundle these payments in the in-network facility fees they charge insurers. This would incentivize hospitals to directly address the problem of surprise billing because if they did not the costs would fall on them. This is consistent with economic theory that recommends placing burdens on those that face the lowest transaction costs to resolve disputes.

The primary difference between these two proposals is their understanding of the root cause of surprise billing. Are surprise bills the natural outcome of failed negotiations between insurers and providers? Then an independent dispute resolution process replaces patients as the final backstop in negotiations. Or are surprise bills a symptom of a flawed system in which bad-faith actors set artificially high prices? The second solution requires hospitals to resolve the problem contractually or be responsible for the surprise bills.” (L)

“One short-sighted “solution” known as benchmarking could actually make things much worse. It would put the government in control of setting payments to physicians by using insurance companies’ in-network averages as the “benchmark” for out-of-network services.

However, since these rates have been deeply discounted during the contract negotiation process, benchmarking would cause local hospitals and emergency rooms to incur significant losses that could translate to diminished access, fewer choices and higher costs for patients.

None of these outcomes are acceptable.

Congress should instead focus on passing a balanced solution that is fair to both providers and insurers while holding patients responsible for only their standard, in-network cost-sharing amounts.

Just such a solution can be found in another proposal called Independent Dispute Resolution, or IDR.

An integral part of our Washington state law is an IDR system that establishes appropriate reimbursement for out-of-network care when physicians and insurance carriers cannot agree on what constitutes “commercially reasonable rates.”

It passed the Legislature overwhelmingly because it was a compromise among physicians, hospitals and insurance carriers.

For our state law to be truly effective, it requires broad participation among health plans, specifically self-insured health plans that have the option to opt in to compliance with the law.

If federal legislation is adopted that does not include an arbitration/IDR component, the likelihood that self-insured plans would opt to comply with the state law is slim to none because the plans would be subjecting themselves to arbitration.

So even though the state law would not technically be superseded, its efficacy would be compromised if federal legislation without an arbitration/IDR provision is adopted.

Conversely, if federal law is adopted with such a provision, it would establish a level playing field for all parties – something that can’t be done at the state level due to federal preemption of self-insured plans.

Additionally, initial payments made at the onset of the IDR process would help keep rural healthcare facilities financially strong and secure, ensuring no one’s access to quality, affordable care is at risk.

Unlike benchmarking, the IDR approach also provides extra incentives for insurance companies to grow their provider networks, helping prevent the kinds of gaps in insurance that lead to surprise medical billing in the first place.”… (M)

“It is the duty of physician companies — not Congress — to end surprise billing, Ashish Jha, MD, a health policy professor at the Harvard T.H. Chan School of Public Health in Boston, wrote in an op-ed for The Boston Globe.

Estimates say more than half of American adults have received a surprise bill from a medical provider they thought was in network, Dr. Jha said. He argues surprise bills aren’t really an accident, but “an intentional exploitation of weaknesses in our healthcare system” by physician groups who refuse to contract with insurers.

“These physician groups will argue that insurers aren’t negotiating in good faith, and while sometimes that’s true, the primary culprit of this deception has been physician companies whose business model is to exploit patients when they are most vulnerable — in an emergency or under anesthesia,” he wrote.

While mandatory arbitration has been floated as a possible solution, Dr. Jha thinks capping how much providers can charge for out-of-network services is a better solution that will encourage physician companies to negotiate with insurers.

“We all took an oath to ‘do no harm.’ To financially ruin our patients when they are sick shows a moral rot in our community,” Dr. Jha said. “If we don’t voluntarily stop this practice, Congress will eventually stop us. And shame on us for making Congress do what we should do on our own.” (N)

“In a new paper, coauthor Brian Blase and I propose a market-based solution to such surprise medical bills. This proposal, if implemented, will equip consumers with the information they need to so they can make more informed health care decisions.

Our proposal requires insurers and providers to supply accurate and timely information about networks and prices. It segments the surprise billing problem into four distinct categories, depending on the network status of the facility and whether the medical services are emergency or nonemergency.

Here are the three major elements of our recommendations:

1. Price disclosure. Unlike virtually every other service in the economy, consumers don’t know the prices of scheduled, nonemergency care until long after receiving it. The government does not need to mandate price disclosure in other areas of the economy that function efficiently. But efficiency is not a key feature of health care markets, which are beset by excessive third-party payment and price opacity.

Congress should correct this problem by requiring providers to supply a good faith estimate of the cost of scheduled medical care before it occurs, unless the patient affirmatively declines an estimate. Providers that refuse to supply an estimate before providing care could not “balance bill” (i.e., charge a patient an amount above what the insurer pays the provider) afterward.

2. Penalties on insurers and providers for supplying false and misleading information about a facility’s network status. Consumers typically seek network physicians and hospitals to avoid high out-of-network bills. They rely on representations about network status from their insurance company and from the hospital itself.

What their insurer and hospital often don’t tell patients is that other doctors who might participate in their care are not part of their insurer’s network. Patients learn that only weeks or months later, when the bill from the non-network physician arrives.

Congress should protect consumers against false and misleading information. It should establish penalties for insurers that represent a facility as being in-network, and a facility that presents itself as being in-network, if doctors balance-bill for services they provide at that facility.

To be considered a network facility, the insurer, the facility, and the doctors who practice there would have to negotiate arrangements that protect patients against surprise bills. Hospitals that permit surprise bills could not be represented as network hospitals without penalty.

3. Ban balance billing at non-network emergency departments. Accurate information about a hospital’s network status and price transparency don’t help the patient who is suffering severe chest pains or being transported in an ambulance. Such patients generally will go or be taken to the nearest emergency room. Broad consensus exists in Congress and among the public that patients in those circumstances should not face large bills for out-of-network care.

Consistent with that consensus, we propose that Congress ban surprise billing in these limited circumstances and require insurers to pay, and providers to accept, reimbursement rates spelled out in existing federal regulations.

Those regulations, which already govern insurance company payments to non-network providers of emergency care, require insurers to pay providers the greatest of: a) the Medicare rate; b) the median network rate; or c) the amount an insurer generally pays non-network providers.

The alternatives—such as doing nothing and arbitration—are worse, and accurate information about network status and prices are of no value in this unique circumstance.

These recommendations should, to the extent possible, be implemented in a way that preserves the ability of states to adopt policies that best serve their residents.

This proposal offers a better path for Congress, which currently seems headed in a very different and counterproductive direction. Although they differ in some respects, the House and Senate proposals rely on sweeping and unnecessary federal price regulation, rather than market-based alternatives, to eliminate balance billing. Both would force doctors and insurers who have not contracted with each other to accept rates set in contracts they haven’t signed.”  (O)

“Comprehensive state laws hold consumers harmless against surprise medical bills. The hold-harmless protection generally involves two types of requirements – one for state-regulated health insurers, and one for providers. Insurers are required to cover out-of-network claims and apply in-network level of cost sharing for surprise medical bills. In addition, laws prohibit providers from balance billing patients covered by state-regulated plans; instead, the out-of-network provider is limited to collect no more than the applicable in-network cost-sharing amount from patients in cases of surprise medical bills.

State laws may also require notice to consumers about their rights and protections. New York, for example, requires state-regulated insurers to include prominent, standardized notice on the explanation-of-benefits (EOB) statement summarizing consumer rights regarding surprise medical bills. Notices also give consumers information about where they can file complaints or receive help. In California and New Mexico, out-of-network providers also are required to include prominent notice in billing invoices and other written communications pertaining to surprise medical bills that the consumer is not liable to pay more than the in-network cost sharing amount.

Resolve payment for surprise bills

After indemnifying the patients, comprehensive state laws then provide for resolution of the payment amount for surprise medical bills. Approaches vary, with some states adopting a payment standard for all applicable surprise medical bills, while other states establish a dispute resolution process that insurers and providers can use to arrive at a payment amount for each surprise medical bill. States sometimes use a combination of both approaches.”  (P)

“Instead of waiting idly for Congress to act — and action is by no means certain — consumer advocates and payers ought to exploit the significant legal vulnerabilities to physician staffing firms’ out-of-network business model. Opening a second front with targeted legal challenges might shift momentum in the legislative fight against surprise medical bills…

Although different states have different rules about a hospital’s qualification for a not-for-profit exemption from taxation, in general hospitals must adhere to a charitable mission and not become vehicles for a profit-making enterprise. In 1998, the Pennsylvania Superior Court upheld revoking the tax exemption for a hospital that had transferred funds to an affiliated medical practice. The court held that because the medical practice did not provide charity care and used noncompete covenants, the hospital was supporting a for-profit entity.

Not-for-profit hospitals are granting franchises to staff their emergency departments to for-profit companies that aggressively bill the captive clientele attracted by the hospitals’ network participation while declining to join those networks themselves. An affected community loses twice: paying higher tax rates to offset the hospital’s exemption while also paying exorbitant prices for services that hospitals claim as a “community benefit.”

A strong argument can be made to taxing authorities that this is inconsistent with a nonprofit mission.

It’s time to pilot legal challenges to surprise medical bills

Litigation has played an important role in improving health and health care. Lawsuits against tobacco companies led to changes that drastically curbed smoking; similar litigation is changing the face of opioid production, distribution, and prescription. Malpractice lawsuits over deaths from anesthesia resulted in huge improvements in patient safety.

Applying legal pressure on the staffing firms and their host hospitals could bring a relatively quick and inexpensive change of the “facts on the ground” and break impasses in both legislative and network contracting negotiations. It would be helpful to have such activities running in the background during Congress’s 2020 session.” (Q)

“House Majority Leader Steny Hoyer (D-Md.) said Wednesday that two Democratic committee chairmen are trying to work out their differences over a measure that would protect patients from surprise medical bills.

A bipartisan group of lawmakers has been pushing for months to pass legislation protecting patients from getting massive bills when they go to the emergency room and one of their doctors happens to be outside their insurance network. That effort was derailed last month when House Ways and Means Committee Chairman Richard Neal (D-Mass.) and ranking member Rep. Kevin Brady (R-Texas) proposed an approach that differs from the bill put forward by House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.) and Rep. Greg Walden (Ore.), the top Republican on the panel.

“Mr. Neal and Mr. Pallone are talking and the committee members are talking about the differences,” Hoyer told reporters when asked if he or Speaker Nancy Pelosi (D-Calif.) would step in to try to resolve the dispute. “It’s like infrastructure — there’s universal agreement that we need to deal with surprise billing. There obviously are differences with respect to how you deal with that, and they’re discussing that now.”

Hoyer added that hopefully they can “resolve those differences and move ahead in a way that will protect patients.”..

Pelosi has said she hopes surprise billing legislation will be included in a health care package ahead of a May 22 deadline for renewing certain expiring health programs.” (R)

Experts warn that some providers — such as hospital staffing companies backed by private equity funds — avoid joining networks to cash in on the lucrative world of surprise billing. That lets them charge more than the rates negotiated by insurance companies.

A Stanford University analysis of millions of insurance claims found more than 80% of ambulance rides fell outside patients’ insurance networks. New research from Yale University, meanwhile, estimates that reining in out-of-network billing by anesthetists and others could cut health care spending by tens of billions of dollars annually.” (S)

“America’s sky-high health-care costs are so far above what people pay in other countries that they are the equivalent of a hefty tax, Princeton University economists Anne Case and Angus Deaton say. They are surprised Americans aren’t revolting against these taxes.

“A few people are getting very rich at the expense of the rest of us,” Case said at conference in San Diego on Saturday. The U.S. health-care system is “like a tribute to a foreign power, but we’re doing it to ourselves.”

The economists say they understand it will be difficult to alter the health-care system, with so many powerful interests lobbying to keep it intact. They pointed to the practice of “surprise billing,” where someone is taken to a hospital — even an “in network” hospital covered by their insurance — but they end up getting a large bill because a doctor or specialist who sees them at the hospital might be considered out of network.

Surprise billing has been widely criticized by people across the political spectrum, yet a bipartisan push in Congress to curb it was killed at the end of last year after lobbying pressure.

“We believe in capitalism, and we think it needs to be put back on the rails,” Case said.” (T)

“About a year ago, I began to have stomach discomfort and thought I had overdone it at Starbucks….continued

“But there was no time for discussion. I was wheeled off for a straightforward surgery that took about 35 minutes — not much longer than a colonoscopy. The procedure went well.

Eventually, the surgeon’s bill arrived: $17,000 including charges for an ER consult neither my husband nor I recall. I called the insurance company (for which we’re paying more than $25,000 in annual premiums). Sorry, he’s not one of ours. No contract with us.

Fortunately, my insurance covered all other related hospital costs — the ER doctors and tests, the operating room, medications, the anesthesiologist’s fee — but that still left us with the $17,000 charge from the surgeon. That’s more than seven times the out-of-network, uninsured rate for the hospital’s locale, according to FAIRHealth Consumer.

I appealed to the Maryland Insurance Administration, which regulates the state’s insurance industry. MIA was sympathetic, but there was nothing to be done because the surgeon didn’t have a contract with the insurance company.” (U)

“Lawmakers concede escalating tensions with Iran and impeachment could cripple progress on deals for surprise billing as a stalemate over how to pay providers lingers…

Lawmakers didn’t include legislation on surprise billing in an end-of-year spending package. But in that package, Congress only reauthorized funding for key health programs until May.

The thinking was to create a new deadline for Congress to get something done on surprise billing and other healthcare legislation. However, the Senate is waiting on the House to sort out a way forward.

How to pay providers has remained a key sticking point, as providers endorse arbitration to settle disputes on out-of-network charges and payers a benchmark rate for out of network. Provider groups, some of which are backed by private equity firms, and insurers have launched massive ad campaigns over the issue.

The House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions Committee reached a deal last year that uses a benchmark rate and an arbitration backstop for any charges above $750. But the House Ways and Means Committee announced shortly thereafter they are working on their own legislation that may be more provider-friendly.

The stalemate has continued into the new year.

House Majority Leader Steny Hoyer told reporters last week that he is turning to the committee chairmen to settle any dispute, according to a report in The Hill newspaper. Energy and Commerce Committee Chairman Rep. Frank Pallone, D-New Jersey, calls tackling “devastating” surprise medical bills one of his top priorities, a committee spokesperson said.” (V)

Share on LinkedInShare on Google+Share on FacebookTweet about this on Twitter