Surprise Medical Bills / Out-of-Network Payment

Out-of-network billing, or “surprise medical bills” occur when a patient receives a bill for the difference between the out-of-network provider’s fee and the amount covered by the patient’s health insurance, after co-pays and deductible. Patients often assume that facility-based providers—such as radiologists, pathologists, physician anesthesiologists and emergency physicians—are in-network because their surgeon and hospital are in-network. Using New York as a model, Congress should act to hold patients “harmless” from unanticipated bills. Patients should be responsible for only their in-network out-of-pocket expenses in emergency and unexpected settings.

Physician anesthesiologists recognize being a provider in their patients’ health plans is better for patients, easing both expenses and paperwork burdens. It is also better for providers easing billings and administrative responsibilities. While there are circumstances where physician anesthesiologists may not be in a patient’s network, data indicates that the vast majority of claims for anesthesia services – more than 90% – are in their patients’ health plans or “in-network,” thereby limiting patient exposure to “surprise medical bills.”

To address “surprise medical bill” situations, ASA Urges Congress to:

Hold Patients Harmless for Unanticipated Medical Bills – Ensure that patients would be responsible for only their in-network out-of-pocket expenses in emergency and unexpected settings.
Ensure Enforceable Network Standards as an Essential Part of Fixing this Problem –When the government requires insurers to have adequate networks, and regulators hold them responsible for maintaining an adequate network, there will be fewer circumstances in which patients are surprised to learn they had or could be treated by an out-of-network provider, especially in situations where the care was unexpected.
Identify Fair Solutions to Ensure Appropriate Payments to Providers – Using Medicare as a benchmark for payment is unworkable for many specialties, including anesthesiology.
Utilize an Independent Dispute Resolution System to Resolve Disputes Between Physicians and Insurance Companies – A binding arbitration or “baseball style” arbitration involving providers and insurance companies is a proven model for efficient and cost-effective resolution of payment disputes.
Look to New York State as a Functioning Model – New York has a law that requires hospitals, physicians and plans to provide clear information about networks and charges, and requires plans to only offer adequate networks. The law sets up a market-based reasonable usual, customary and reasonable payment definition to guide resolution process toward a fair and reasonable payment solution.

ASA has endorsed the “Protecting People from Surprise Medical Bills Act,” a proposal introduced by a bipartisan group of lawmakers led by Congressmen Raul Ruiz, M.D., and Phil Roe, M.D. Read more about this proposal.

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