Imagine for a moment that someone in your family experiences a sudden medical emergency. It’s happened to my loved ones. It’s probably happened to someone dear to you.
In that moment, your first reaction is a mix of fear, anxiety, and sadness. And then, in an instant, one thought takes over: The urgency of finding the best care without delay.
When the crisis is over, you feel a sense of relief and gratitude that your loved one received timely, skilled medical care when it was needed.
But sometimes, there’s a post-emergency shock that arrives when people learn the insurance company won’t pay its fair share of the bill for their emergency care.
That leaves the patient on the hook for the unpaid amount. This is commonly known as “balance billing.”
It typically occurs when an insured patient receives care from a health care provider who is not in-network with their insurer.
This year, the General Assembly is considering legislation to protect patients from balance billing. President Trump is also focused on it; he recently called for a solution that shields patients from harm in those situations.
Del. Lee Ware of Powhatan County is leading the way on this issue by carrying a bill to protect patients from the hardship of unexpected medical bills. His proposal simplifies a complicated situation by asking more of health care providers and insurers.
In emergency situations when patients don’t have a chance to check if a provider is in-network prior to treatment, Ware’s HB 1714 establishes a fair standard for all parties involved.
The bill specifies that patients won’t be required to pay an out-of-network provider more than their typical cost-sharing payment (such as an out-of-pocket deductible or a co-pay) for in-network treatment.
Rather than leaving patients on the hook for the balance of an unexpected medical bill, it would require insurance companies to pay an equitable share of treatment costs that are consistent with the in-network value for a service.
Another protection in the bill would apply to patients who seek emergency services believing they are experiencing a serious medical episode that later turns out to be less serious than initially feared. In such cases, an insurance company would be prohibited from denying coverage for a patient’s medical claim after the fact.
Ware’s bill has widespread support. The only significant opposition to it comes from mammoth insurance companies. They prefer HB 2544 from Del. Kathy Byron of Campbell County, which may be well-intentioned but it gives insurers more leverage in balance billing situations.
The idea that a person with insurance should be covered for medical care they receive seems so obvious that you might wonder why this is even an issue.
The fact is, there are several market factors at play.
One is a shift in how people pay for health care services. You may have noticed that more insurance plans have moved from co-pay plans to high-deductible plans with health savings accounts.
The goal of that is to limit insurance costs by shifting them to patients and decreasing health care utilization.
Another consideration is the complex relationship between commercial health insurance and how providers, including physician specialists and the hospitals in which they work, are reimbursed.
Although you might assume that the doctors who treat you in the emergency department are employed by the hospital, the reality is that many of those physicians who specialize in things like radiology and anesthesiology staff the hospital under contract agreements.
The hospitals that work with those doctors want to uniformly be in-network with all the same insurers as the doctors on staff.
Yet insurance companies ultimately determine which providers are in-network and the rate at which they are willing to reimburse providers for services.
That means they have the power to deny insured patients’ claims, to limit patients’ access to providers who aren’t in-network and to set rates that don’t fairly reimburse health care providers for care rendered.
Ware’s HB 1714 is a common-sense solution that protects patients and families from surprise medical bills while respecting the roles that providers and insurers play in the health care delivery system.
And it is in line with the goals articulated by President Trump to bring more transparency and affordability to the health care system.
Read the full report from The News & Advance.