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.
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.
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:
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:
More facts on Surprise Billing Billing
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.