At its core, the American health system is not about health. It’s all about money.
Nothing illustrates that better than the years-long fight over surprise medical bills that finally ended when Congress passed the Omnibus Appropriations and Emergency Coronavirus Relief Act as 2020 came to a close. You know those are the bills both small and large that would show up unexpectedly after you and your insurance company had paid for your care.
Too often patients found they owed hundreds, sometimes thousands of dollars, after they had thought insurance payments along with their cost-sharing obligations — deductibles, co-pays, and coinsurance — had taken care of the bill. Many times those bills came from emergency room doctors and anesthesiologists when patients suffered medical emergencies — not an ideal time to be asking about billing practices.
A case in point a few years ago was the story of a 44-year old Texas high school teacher who found himself with a $108,957 bill after suffering a heart attack. Some of the doctors who treated him during his emergency were not in his insurer’s network. Widespread publicity, including a story on NPR, prompted the hospital to reduce the bill to $332.
Other families haven’t been as lucky, and over the years the problem worsened. One study in the Journal of the American Medical Association found that more than 20% of 350,000 patients received out-of-network charges averaging over $2,000 more than their insurers would pay. Another report from the Federal Reserve Board found that 40% of Americans could not easily cover an unexpected emergency expense.
Legislation put into the omnibus bill to solve the billing problem did not come easily.
For several years doctors, hedge funds that own physician practices, and hospitals fought against employers and insurance companies in state and congressional battles to end surprise billing. In the December legislation the doctors’ won when Congress agreed to take patients out of the picture and called for disputes to be settled by arbitration favored by doctors who thought that method would result in higher fees for them.
Insurers and employers argued for a different payment mechanism — a set of pre-set benchmarks that doctors argued would reduce their incomes. Tom Nickels, a vice president of the American Hospital Association, argued benchmarks “would reduce what hospitals and doctors were paid for in-network services and out-of-network services too.” Health insurers predicted “increased costs and high premiums as private equity firms exploit the arbitration process.”
“The law is not everything we wanted,” says Chuck Bell, program director for advocacy at Consumer Reports. “We got consumers out of the middle of billing disputes making providers and payers to work it out. We wanted to make sure premiums wouldn’t go up, but the jury is still out on that.”
Bell warned that some doctors like anesthesiologists and radiologists who were “very aggressive in balance billing may become quite active in bringing arbitrations, and that may push rates up.”
One other big improvement for patients is that the new law covers health plans from their employers that are considered self-insured plans under ERISA, the Employee Retirement Income Security Act passed in 1974. Billing disputes of employees covered by these plans will also be eligible for arbitration. That provision will be a big help to millions of Americans who receive health insurance under an ERISA plan.
Disputes with air ambulances will also be covered. In recent years, balance billing disputes by air ambulance companies have plagued many people living in remote rural areas.
Ground ambulance companies whose services often generate surprise bills were not included. We can only guess at the legislative deals that kept them free from regulation.
If any sector needs new regulations governing their billing practices, it’s the ambulances. What person with a serious medical event is going to look for their insurance papers to find out whether the ambulance that arrives is in or out of your insurer’s network?
Still, there are a few things that you can do. If there’s time, find out if an ambulance is in your insurer’s network, which might be the case in a non-emergency like going to a rehab center. You can try to negotiate with the ambulance company to lower its bill. Also ask your insurer for a review of your claim. Contact your state insurance department and outline the specifics of your problem.
Of course, contact your representatives in Congress. Continuing complaints about ground ambulances just might make them address this huge omission in an otherwise decent law to protect consumers.
Trudy Lieberman, a journalist for 40 years, is a fellow at the Center for Advancing Health.
