Surprise Billing

What is surprise billing?

Imagine going to the emergency department, whether for stomach pain, a cut or broken bone, or as the result of a traumatic event. In any case, the emergency department is required by law – and moral obligation – to treat the patient. Unfortunately, some patients have insurance that considers certain emergency treatment out-of-network, and that patient will later receive a “surprise” medical bill from the provider to cover the cost of care. This is a practice known as balance billing.

  • A surprise bill is a charge billed by the provider (a doctor, specialist, or technician) who the insurance company does not cover because it deems the healthcare provider out-of-network.
  • A surprise bill is not a deductible, co-payment, or co-insurance or any amount deemed to be the patient’s responsibility as part of an in-network plan.

How does a surprise bill occur?

Patients are often shocked and upset (rightfully so) to find that the health insurance product they pay for is not providing the coverage it should. Knowing emergency physicians must treat all people regardless of ability to pay or insurance status, payers use the federal law – the Emergency Medical Treatment and Labor Act, or (EMTALA) – to offer physicians unfair reimbursement rates that are unsustainable for physicians and emergency departments. Some physicians instead are forced to stay out of network and bill patients for care, creating a “surprise” bill.

This phenomenon might also be referred to as the surprise insurance gap.

How does this affect the patient?

Patients are led to believe that their health insurance company will cover the cost of all – or the majority of – medical expenses. This is not the case in modern America.

Insurance companies are charging higher premiums and providing less coverage than in the past, and patients are often stuck with higher out-of-pocket costs with higher deductibles and co-insurance.

To enroll more people, insurance companies offer plans with “affordable” premiums that often leave the patient with very little coverage for emergency medical costs. This shifts cost to the patient and medical providers, and enriches the insurance companies.

  • Fifty five percent of voters reported paying more for insurance coverage than they have in the past. (Morning Consult, 2016)
  • Twice as many Americans said that their insurance coverage has gotten worse (30 percent) in the past year, compared to those who said that it had gotten better (15 percent). (Morning Consult, 2016)

What is VACEP doing to fix the issue?

Finding a fix for surprise medical bills guarantees access to quality care and ensures emergency rooms remain a “safety net” for all Virginians. In 2019, the Virginia College of Emergency Physicians is supporting legislation to end balance billing while providing fair reimbursement for physicians.

Our proposed solution:

Ensures fair reimbursement to emergency physicians for out of network services. 

We support a ban on balance billing in a manner that also protects emergency physicians who provide EMTALA-mandated care. When a patient goes to an in-network hospital for emergency care, but the physician is out-of-network, the patient will not be required to pay the difference. Instead, providers will be paid a reasonable, regional average of commercial payments for the care they provide.

A change to state law also protects patients by:

Prohibiting “balance billing” patient in the emergency department.

  • When a patient goes to an in-network hospital for emergency care, but the physician is outof-
    network, the patient will not be required to pay the difference.
  • Instead, providers will be paid a reasonable, regional average of commercial payments for
    the care they provide.

Ensuring care is covered, regardless of the final diagnosis.

  • Health plans should not be able to refuse to cover the care their client receives if it turns
    out that the patient wasn’t having an emergency.
  • EXAMPLE: If a patient goes to the emergency department with heart attack symptoms and after medical screening and testing, the physician determines it wasn’t a heart attack the health plan should still have to cover the services and not deny coverage, leaving the patient with a surprise bill.

Removing patients from the billing process.

  • Health insurers will directly pay providers for care. Patients will not be required to send a check from their insurance company to the physician. That’s an unnecessary burden and often leaves the patient confused and liable for the payment themselves.
  • Patients are only responsible for deductibles, co-payments, or co-insurance or amounts deemed the patient’s responsibility towards in-network care.

More facts on Surprise Billing Billing

  • One in four (24 percent) Americans said that they have lost access to primary care and specialist doctors because of shrinking networks created by their insurance company. (Morning Consult, 2016)
  • In one poll, 80% of emergency physicians said that they treated patients who could not find a medical specialist to care for them because their health plan limited the number of medical providers available to them. (ACEP Poll, 2015)
  • Nearly one in four Americans said that their medical condition got worse because they did not seek immediate emergency medical care out of fear that their health insurance company would not cover the cost. (Morning Consult, 2016)

How does this affect patients and emergency medicine providers?

Emergency departments across the country are feeling the harmful effects of the Out of Network Services practice. The financial costs to keep emergency departments open and fully staffed 24 /7/365 are astronomical. As insurance companies provide less and less coverage, patients are often times unable to pay their medical bills. When this occurs, the hospital or emergency department loses money, but is still responsible for covering the cost of running an expensive emergency department. For this reason, emergency departments around the country are shutting their doors and closing permanently, leaving patients without access to emergency medical care.