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CD199: Surprise Medical Bills

Congressional Dish

Release Date: 06/30/2019

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Almost 40% of Americans WITH health insurance reported they had received a surprise medical bill in the past year from a doctor or hospital for a service they thought was covered by their insurance plan. Why is this happening? And what can we do about it? 

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Hearing: NO MORE SURPRISES: PROTECTING PATIENTS FROM SURPRISE MEDICAL BILLS, Not on C-Span, Committee on Energy and Commerce, June 12, 2019.

Watch on Youtube


  • Sonji Wilkes: Patient Advocate
  • Sherif Zaafran, MD: Chair of Physicians for Fair Coverage
  • Rick Sherlock: President and CEO of Association of Air Medical Services
  • James Gelfand: Senior Vice President of Health Policy at The ERISA Industry Committee
  • Thomas Nickels: Executive Vice President of the American Hospital Association
  • Jeanette Thornton: Senior Vice President of Product, Employer, and Commercial Policy at Americas’ Health Insurance Plans
  • Claire McAndrew: Director of Campaigns and Partnerships at Families USA
  • Vidor E. Friedman, MD: President of American College of Emergency Physicians


  • 47:54 CEO Rick Sherlock: Emergency air medical services are highly effective medical interventions appropriate in cases where getting a patient directly to the closest most appropriate medical facility can make a significant difference in their survival in recovery. Today, because of air medical services, 90% of Americans can reach a level one or level two trauma center within an hour. However, since 2010, 90 hospitals have closed in rural areas and an estimated 20% more are at risk of closing. Our members fill the gap created by closures, but this lifeline is fraying as 31 air medical bases have also closed in 2019.

  • 48:31 CEO Rick Sherlock: Emergency or medical providers never make the decision on who to transport. That decision is always made by a requesting physician or medically trained first responder. Air medical crews then respond within minutes, 24 hours a day, seven days a week without any knowledge of a patient’s ability to pay for their services.

  • 48:45 CEO Rick Sherlock: Our members are unique in the healthcare system. The services heavily regulated by the states for the purposes of healthcare, as ambulances and the federal government for aviation safety and services as air carriers. It is their status as air carriers that allow rapid transport of patients over significant distances. Over 33% of our flights cross state lines every day. For that reason, the Airline Deregulation act uniform authority over the national airspace is essential to the provision of this lifesaving service. Exempting air medical services from the ADA would allow states to regulate aviation services, including where and when they’re able to fly, limiting access to healthcare for patients in crisis.

  • 49:54 CEO Rick Sherlock: To prevent balance billing, our members are actively negotiating with insurance companies to secure in-network agreements. One member alone has increased their participation from 5% to almost 43% in the last three years. Despite that, some insurers have refused to discuss in-network agreements. That hurts both patients and caregivers.

  • 50:30 CEO Rick Sherlock: Uh, covering air medical services in full, represents about a $1.70 of the average monthly premium.

  • 51:50 CEO Rick Sherlock: $10,199 was the median cost of providing a helicopter transport. While Medicare paid $5,998, Medicaid paid $3,463 and the uninsured paid $354. This results in an ongoing imbalance between actual costs and government reimbursement and is the single biggest factor in increasing costs.

  • 53:45 Senior VP James Gelfand: We’re focused on three scenarios in which patients end up with big bills they couldn’t see coming or avoid. Number one, a patient receives care at an in-network facility, but is treated by an out of network provider. Number two, a patient requires emergency care, but the provider’s facility or transportation are out of network. And number three, a patient is transferred or handed off without sufficient information or alternatives. It’s usually not the providers you’re planning to see. It’s anesthesiologists, radiologists, pathologists, or emergency providers or transport or an unexpected trip to the NICU. Many work for outsourced medical staffing firms that have adopted a scam strategy of staying out of networks, practicing at in-network facilities and surprise billing patients. It’s deeply concerning, but the problem is narrowly defined and therefore we can fix it.

  • 54:40 Senior VP James Gelfand: The No Surprises Act nails it. It takes patients out of the middle and creates a market based benchmark rate to pay providers fairly. The benchmark is not developed by government and it is not price setting. The committee might also consider network matching. It’s simple. If a provider practices at an in-network facility, they take the in-network rate or they go work somewhere else. Or base the benchmark on Medicare, you could set the rate higher, say 125% of Medicare and still make the system more affordable, sustainable and simpler. These approaches will eliminate the surprise bills. That’s a huge win for patients.

  • 54:50 ** Senior VP James Gelfand: But not everyone wants to stop the surprise bills. Some provider specialties are saying, “let us keep doing what we’re doing, just use binding arbitration to make someone else pay these bills”. They’re asking for a non- transparent process that could force plans and employers to pay massive and fake medical list prices. It’s essentially setting money on fire. Funds that would have been used to pay for healthcare will instead be spent on administrative costs such as lawyers, arbitrators, facility fees, and on reasonable settlement amounts. Make no mistake, patients will pay these costs.

  • 55:20 Senior VP James Gelfand: The ground and air ambulance companies are asking Congress to let them keep surprise billing too. Do nothing, wait for another study, another report, and there have already been four. They know patients cannot shop for them and many participate in no networks. State insurance commissioners are begging for help with air ambulances, but Congress has tied their hands. Employers think Congress should end this. Treat medical transport the same as emergency care. We should end surprise billing in the ER and on the way there.

  • 56:30 Senior VP James Gelfand: Other providers figure they’re willing to stop surprise billing, but only if they can increase in-network rates. They’re calling for network adequacy rules to force insurers and employers to add more providers to their networks, even if those providers demand astronomical payments. Does anyone here actually believe that these hospital based doctors who services cannot be shopped for, who are guaranteed to see our patients, are begging to be included in our networks, but nobody will return their calls? That they have no choice but to go and join these out of network Wall Street owned firms? It doesn’t make sense.

  • 57:00 Senior VP James Gelfand: Employers design health benefits to help our beneficiaries. We don’t sell insurance. We want networks that meet our patients’ needs. Why would we want to cover an operation, but leave out the anesthesia? We want our employees to be able to afford their health insurance too, and that means we must be able to say no when providers are gaming the system.

  • 1:08:10 Dr. Vidor Friedman: Unlike most physicians, emergency physicians are prohibited by federal law from discussing with a patient any potential costs of care or insurance details until they are screened and stabilized. This important patient protection known as Emtala, ensures physicians focus on the immediate medical needs of patients. However, it also means that patients cannot fully understand the potential cost of their care or the limitations of their insurance coverage until they receive the bill.

  • 1:10:40 Dr. Vidor Friedman: The goal should be a system in which everyone is in-network, or essentially that. That requires a level playing field between providers and insurers. Insurers are concerned that benchmarking the even median charges, favors providers. Providers are concerned that benchmarking the median in-network rates, favors insurer’s. What’s Congress to do? ACEP supports a system that has already proven to be balanced between insurers and providers. That is a baseball style independent dispute resolution process similar to that used in New York and noted in the legislative proposal put forth by Doctors, Ruiz Rowe and Busan.

  • 2:02:30 Rep. Brett Guthrie: If there does become a federal arbitration system, what do you think congressional oversight should be? And I don’t know if that should be something that I’m supposed to talk about or…Sonji Wilkes: Well, I’ve been sitting here listening, thinking I pay my insurance premiums, I do my part and I expect the bill to be paid. I mean, there’s only so much I can do to control that and I don’t really care how the reimbursement works. And quite frankly, I think the insurance industry is doing probably better in their bottom line than my bottom line. Um, I want to go to the best provider possible and I want the best care possible. I don’t really care how the payment works.

  • 2:34:50 Dr. Sherif Zaafran: Well, I can tell you that from the physician’s standpoint, for emergency room physicians for example; the average weighted cost of every visit is about $155.

  • 3:49:00 CEO Rick Sherlock: The median cost of a helicopter air transport is $10,199 according to a study conducted in 2017. If you look at the cost of uncompensated care, because Medicare pays less than $.60 on the dollar of that 10,199. About $5,998, Medicaid pays significantly less than that. Less than $3,500 on average, and the uninsured pay about $350. Those make up…those three groups make up 70% of air medical transports. So when you take that cost of uncompensated care and you add it to the median cost of $10,200, that’s the average charge of $36,000 that the representative from New Mexico referenced earlier. When you…when those kinds of situations happen, no one in our industry wants to see a patient or their family placed in jeopardy because they’ve just had a health emergency. Our members will sit down with each individual and their families and work out a solution tailored for them.

  • 3:54:30 Dr. Sherif Zaafran: Again, there is no such thing as an out of network provider. There is a provider who may happen to be out of network with that specific product. So the only one who knows what the product is, is of course the patient and the insurance carrier and they’re the only ones who really have the information as to whether they’re in-network or out of network.

Hearing: The Need to Reauthorize the September 11th Victim Compensation Fund, June 11, 2019

Hearing: Hearing on September 11 Victims Compensation Fund, June 11, 2019


Watch on CSPAN-Surprise Medical Bills House Ways and Means Subcommittee on Health-May 21, 2019

Committee website

Watch on YouTube


  • Rep. Katie Porter (CA)
  • James Patrick Gelfand: Senior Vice President, Health Policy, ERISA Industry Committee
  • Dr. Bobby Mukkamala: Board of Trustees, American Medical Association
  • Tom Nickels: Executive Vice President, Government Relations and Public Policy, American Hospital Association
  • Jeannette Thornton: Senior Vice President for Product, Employer, and Commercial Policy at America’s Health Insurance Plans (AHIP)


  • *7:15 Chairman Lloyd Doggett (TX): Fortunately, there now appears to be a growing consensus. Most recently joined by president Trump that holding the patient harmless should form the foundation for any surprise billing proposal. Under the legislation that I advanced, patients would only be charged in network cost sharing rates in emergency situations and non-emergency situations out of network charges would be permitted only when the patient has agreed in advance after receiving effective notice regarding any providers and services together with estimated charges. No other bill addressing this issue has yet been filed here in the house, but there is a very useful discussion draft proposal that is being circulated on a bipartisan basis by the House Energy and Commerce Committee and there’s several proposals that have service in the Senate. While every proposal currently begins with the basic premise of the enterprise billing act, conflict remains over how to resolve insurer provider disputes.

  • *13:40 Rep. Katie Porter (CA): I’m concerned about surprise billing, as someone who’s dedicated my life to protecting consumers, but also because I have had to fight my own battle with surprise billing. On August 3rd last year when I was on the campaign trail, I started to feel pain in my abdomen. At 1:00 PM I could not continue and I went home. At 4:31, I texted my campaign manager that I needed to go to the emergency room. I couldn’t safely drive through the pain and I remember sitting on my front porch, so if I lost consciousness, somebody might find me and I wouldn’t be home alone. I didn’t call an ambulance because I was concerned about the cost. I could not drive and I asked my manager to please take me to Hoag hospital. I chose that hospital even though it was farther away from other providers, because I knew Hoag was an in-network facility. When I got to the hospital, I waited six hours alone in the emergency exam room without treatment. When I finally went to surgery, my doctor told me it was nothing to worry about, just a routine appendectomy. I was given anesthesia and when I awoke, the team around me was panicking. They couldn’t get my temperature to drop and they couldn’t get my blood pressure to rise. My appendix had ruptured hours before causing an infection that was making my whole body very sick. I spent the next five days in the hospital receiving powerful IV antibiotics. A few weeks later, I received the bill from my insurance company. The idea of an astronomical hospital bill had weighed heavily on me and I was happy to see that the cost of my emergency room treatment and assessment and hospital charges, and nearly all of my inpatient services, were covered. I remember sitting at my kitchen table and taking a deep breath filled with relief, but a few days later I received another bill. This one from my surgeon. While the hospital I had gone to was in-network, the insurance company now claimed the surgeon was not, even though they had sent me a notification telling me that my surgeon was in-network . Enclosed in that bill for nearly $3,000, was a handout from my surgeon detailing the steps I would have to take while recovering in order to fight to have my insurance company cover the care. So many of his patients had been put in this situation, that this medical doctor had used his staff to address patient billing problems. That’s not what he trained for in medical school. Your so-called explanation of benefits and the surgeon’s handout explained that he was being treated as an out of network provider even though he was employed by and worked at an in-network hospital. As someone in an emergency situation, I had no ability to assess whether he was in or out of network, and in those cases insurers are supposed to cover the costs, but I got that bill because my insurer put profits before patients. I called insurance company to request an appeal. The benefits manager kept asking me questions to guide me and coach me towards saying that it was my surgeon’s fault to blame him for overcharging me. She asked me to call the surgeon and attack my doctor for his bill. Apparently, to Anthem Blue Cross, $3,000 was too high a price for saving my life. The tens of thousands in premiums I’d paid to that company over the years were not enough to have them, cause them to cover the lifesaving care. Nearly five months after I was hospitalized, the surgeon simply requested payment, and at that point I reached out to my employer of the University of California Irvine. That’s when I learned that U.C. Irvine has a designated patient advocate, a medical doctor, whose sole job is to help university employees get the health insurance that the university and the employees pay for. Can we just reflect on that for a moment? The university is paying a medical doctor to do nothing but navigate insurance. Finally, the patient advocate, invoking the fact that I had just been just elected to Congress, was able to get the insurance company to agree to pay my surgeon’s bill. But here’s what I learned from getting sick. I am well educated. I had an employer prepared to help me. I have professional experience fighting for consumer rights, but there are thousands of Americans with fewer resources than me who are surprised with bills far more devastating than mine. I’m here today because they refuse to accept this as the status quo. I refuse to stand idly by while families go bankrupt because of surprise medical bills. Any solution to this issue must rely, must not rely, excuse me, on the patient’s ability to go to war with the insurer or with their provider. That is not the solution. It’s time we start putting patients first.

  • 31:00 Jeanette Thornton: We ask that federal legislation focus on four things. First, balanced billing should be banned in situations where inpatients are involuntarily treated by an out of network provider. This includes emergency health services at any hospital, any health healthcare services or treatment performed at an in-network facility by an out of network provider, not selected by the patient and ambulance transportation in an emergency. Second, health insurance providers should be required to reimburse out of network providers inappropriate and reasonable amount in those above scenarios. Third, state should be required to establish an independent dispute resolution process that works in tandem with the established benchmark. Fourth hospitals or other healthcare providers should be required to provide advanced notice to patients of the network status of the treating providers. We appreciate the health sub-committee chairman Lloyd Doggett has introduced legislation to end surprise billing act or HR 861, which would establish a role for hospitals in providing such notices, along with banning balanced billing. AHIP supports this bill.

  • 46:00 Chairman Lloyd Doggett (TX): What I’m referring to is the difference… Dr. Bobby Mukkamala: Right. Chairman Lloyd Doggett (TX): …in charges and why one one price for those who are in network and another for those that are out. Dr. Bobby Mukkamala: Right. So there is a benefit for me to be in network with Blue Cross Blue Shield of Michigan for example. I get something from that. They sit with me, they show me their data. We had…we worked together on incentive programs to sort of curb costs. If there’s an insurance company that’s in town that does none of that activity to improve the care of the population in my town, but yet wants to benefit from the same rate of compensation to me, they’re doing nothing to earn that discount. Blue Cross sits across from me on a weekly or monthly basis to improve the care of my population. But Golden Rule insurance, that’s new in town for example, doesn’t do any of that work and yet wants to benefit from having the same provider rates. No, I mean, I take a discounted rate from Blue Cross because of all this other robust activity. But if you’re not offering me anything to participate in your network, then naturally, you should be expected to pay more for my services. Right? I get something from Blue Cross. I get nothing from Golden Rule.

  • 53:05 Dr. Bobby Mukkamala: Medicare is usually sort of the foundation upon which all the other insurance companies tend to set their rates. So when I participate in network, like with Blue Cross Blue Shield of Michigan, it’s usually about 110/ 115% of Medicare rates. So that’s one step higher. If I don’t participate with Blue Cross Blue Shield of Michigan, then that rate is so I can get the assigned rate from them and then I have a choice about what to do with the balance. And usually in my practice, I write that off. I don’t balance bill the patient. Uh, but Blue Cross Blue Shield sort of sets their rate and that’s it. My point is that, if-in Blue Cross Blue Shield, I have a great relationship with, we do a lot of constructive work together. But if a new insurance company comes into town and puts up billboards and markets their product and says, here, come, come buy our policy, and then they get 15,000 patients to sign up, but has never come to my door to say, you know, when they have an ear, nose and throat problem, we’d like you to be in-network and provide their care. Why should they get the benefit of the in-network price that Blue Cross Blue Shield gets? So, my point, is that that out of network price for this new insurance company that wants me to take care of their patient, but never came to sit down with me to sign a contract, ought to be something that I negotiate with them, not something that’s dictated to me.

  • 55:50 Rep. Mike Thompson (CA): A staff person of mine went to the emergency room. He has insurance. His insurance covered nearly everything, including a cat scan. But a few weeks later, he got two separate bills from physicians he never saw and didn’t ask to see. They reviewed some of his test results and the bill for those two physicians was larger than the bill for his total ER visit.

  • 56:15 Rep. Mike Thompson (CA): It’s also alarming that, uh, according to one study, 20% of hospital visits, one of every five of those visits, uh, that began in the ER, resulted in a surprise bill.

  • 58:30 Dr. Bobby Mukkamala: Uh, yes, sir. So, in answer to your question, there are multiple already cases documented of insurance companies shrinking their network in California because they can get the same service at that rate with physicians that are out of their network. And so, contracts are already not being renewed for physicians that have had contracts for 20 years, and then they go to renew it and they’re dropped from the network.

  • 1:03:00 Dr. Bobby Mukkamala: My wife and I, we contract with probably about 30 insurance companies. When I take a kid’s tonsils out, one insurance company may be $200- may pay me $200, one pays me about $450 and everything in between. I can’t have a different fee in my fee schedule for each of those. So my fee for tonsillectomy is about $475, so that when I do it, I know that the highest paying payer, I’m still-they’re still within that threshold, right? Because if I charge $400, they’re not going to send me $450. They’re going to send me $400.

  • 1:07:00 Jeanette Thornton: So it’s very interesting what we’ve seen and when it comes from a hospital perspective. It’s maybe only 15% of the hospitals nationwide that are causing this issue that results in, you know, 80% of the visits. One of the statistics had cited a lot that result in a surprise medical bill. So this is not every doctor. This is not every hospital that are resulting in these surprise medical bills. It’s really more of a targeted problem.

  • 1:09:15 Tom Nickels: In terms of how much of this is really going on, I think there is a certain level of frustration. I don’t know that we all know with certainty. The only federal study that I’ve seen, that we’ve seen, is from the Federal Trade Commission, which basically said that they studied ambulances going to hospital emergency departments. 99% of hospital emergency departments in that study were in-network. So it’s not the hospital itself that is out of network. it is people, physicians who practice in our institution.

  • 1:22:20 Tom Nickels: The federal government-state government need to acknowledge that they underpay. I mean, Medpack and others acknowledges that this isn’t just industries talking about ourselves. AMA has said the same thing on the physician side, but I think that the federal government and state governments have a responsibility to pay more adequately. The truth of the matter is, and we haven’t even talked about this, is the cost shift is that private insurers pay more than costs and the government pays less. That should end. The government should take responsibility.

  • 1:38:00 Tom Nickels: We cannot force by law, physicians who are not employed by us to take in-network rates. That is-if we did that, um, we would be sued. It would be restraint of trade. Um, however, what we’re trying to suggest here and I think what the other panelists are trying to suggest, is we have a way to protect the patient from that surprise bill. To your question about who are these physicians that you don’t even know about who are treating you, if you come in in an emergency, you don’t know what’s going on. And you need to be taking care of it, who’s ever there is going to take care of you. The other situation which we’ve talked about is when you knowingly come into an inpatient in-network facility. You did all the right things, but an out of network physician, (anesthesiologists, perhaps radiologists, pathologists) takes care of you. And that’s where the, uh, the bill is generated from. So we cannot make people do that. We try to get physicians to be in our networks-in the same networks. But again, this is an issue of private contracting.

  • 1:42:05 Rep. Mike Kelly (PA): I do agree with you. If there’s limited talent there to take care of that specific problem, there has to be a way of compensating for it. Because at the end of the day, it is a business. Dr. Bobby Mukkamala: Right. So the solution is if an insurance company is going to come into Flint, Michigan and sell insurance, they know that eventually they’re going to need a hand surgeon, right? How do they sell insurance to a town that’s an industrial based town, where there’s a lot of hand injuries and not have any hand surgeons in their network? When they put up the billboard saying, “we’re selling insurance here”, they should have at the same time look at their provider list and say, “you know what”?, we’re missing an orthopedic hand surgeon. "Let’s go find one and figure out how to get him in-network or get her in-network. Right? And that’s a step that’s skipped routinely, right? They’ll sell the product for years and then fill in this way with lack of a good provider network by trying to negotiate out of network rates that are the same as in-network because they’d skip that first step, right? Maintain a network adequacy-establish a network adequacy before you sell your product.

  • 1:48:30 James Gelfand: Many of the hospitals are not doing what Zuckerberg hospital was doing. The hospital will be in-network, but they will have outsourced their emergency room to a Wall Street owned private company and that company won’t take insurance. And those guys are definitely making enough profits that Wall Street is suggesting that people should invest in those companies because of these relationships they have with the in-network hospitals and the out of network emergency rooms.

Trump remarks on medical billing-Watch on C-SPAN, May 9, 2019

  • 13:00 President Donald Trump: Today I’m announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing. And these senators and congressmen and women that are with us today are really leading the charge. And I appreciate that they’re all here. Thank you all. Thank you all for being here. This is fantastic. And I think it’s going to be a successful charge. From what I understand, we have bipartisan support, which is rather shocking. That means it’s very important. That means it’s very good. But that’s great. First, in emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. So-called balance billing should be prohibited for emergency care. Pretty simple. Second, when patients receive scheduled, non-emergency care, they should be given a clear and honest bill upfront. That means they must be given prices for all services and out-of-pocket payments for which they will be responsible. This will not just protect Americans from surprise charges; it will empower them to choose the best option at the lowest possible price. Third, patients should not receive surprise bills from out-of-network providers that they did not choose themselves. Very unfair. Fourth, legislation should protect patients without increasing federal healthcare expenditures. Additionally, any legislation should lead to greater competition, more choice — very important — and more healthcare freedom. We want patients to be in charge and in total control. And finally, in an effort to address surprise billing, what we do is, all kinds of health insurance — large groups, small group, individual markets, everything. We want everything included. No one in America should be bankrupted and unexpectedly by healthcare costs that are absolutely out of control. No family should be blindsided by outrageous medical bills. And we’ve gone a long way to stop that.

Examining Surprise Billing: Protecting Patients from Financial Pain-Not on C-SPAN, House Committee on Education and Labor, April 2, 2019

Watch on YouTube


  • Christen Linke Young: Fellow at USC-Brookings Schaeffer Initiative on Health Policy
  • Ilyse Schuman: Senior Vice President for Health Policy at American Benefits Council
  • Frederick Isasi, Executive Director at Families USA
  • Professor Jack Hoadley: Research Professor Emeritus at Georgetown University’s Health Policy Institute


  • 7:15 Chairman Frederica Wilson (FL): This is the first hearing the United States Congress has held on surprise billing.

  • 7:30 Chairman Frederica Wilson (FL): Surprise medical bills occur when patients covered by health insurance are subject to higher than expected out of pocket costs for care, received from a provider who is outside of their plan’s network. The victims of surprised medical billing often have no control over whether they’re medical provider is in or out of network.

  • 8:15 Chairman Frederica Wilson (FL): A young San Francisco woman named Nina Dang suffered a severe bike accident. She was barely lucid when a bystander called an ambulance and took her to an emergency room at a nearby hospital. Before she knew it, doctors had done x-rays and scans and put her broken arm in a splint and then sent her on her way. A few months later, Nina was hit with a $20,000 medical bill because the hospital, which she did not choose, was an out of network facility.

  • 8:30 Chairman Frederica Wilson (FL): But even patients who are able to take precautions to avoid out of network costs during a medical emergency, are not immune from surprise bills. Scott Cohan suffered a violent attack one night in Austin, Texas. He woke up in an emergency room with a broken jaw, a throbbing headache, and staples in his head. Despite his shock and immense pain, Scott took out his phone and searched through his insurer’s website to make sure he was laying in an in-network hospital bed. When he found out it was, he proceeded with unnecessary jaw surgery. Imagine Scott’s frustration and devastation when he received a surprise medical bill for nearly $8,000. It turned out that the emergency room was in his insurance network, but the oral surgeon who worked in the ER was not.

  • 16:00 Rep. Tim Walberg (MI): 39% of insured working age adults reported they had received a surprise medical bill in the past year from a doctor, hospital, or lab that they thought was covered by their insurance. Of the 39% of individuals who received surprise medical bills, 50% owed more than $500.

  • 27:05 Ilyse Schuman: While a number of states have sought to address this problem or risk that exempts self insured plans from State Insurance Regulations to ensure that national employers can offer uniform health benefits to employees residing in different states. Accordingly, the problem of surprise billing cannot be left to the states to solve.

  • 33:20 Frederick Isasi: So what’s most important to remember about this issue? We are talking about situations in which families, despite enrolling in health insurance, paying their premiums, doing their homework and trying to work within the system, are being left with completely unanticipated and sometimes financially devastating healthcare bills. And this is happening in part, and I want to say this really clearly because hospitals, doctors and insurers are washing their hands of their patient’s interest.

  • 33:50 Frederick Isasi: Take for example, one significant driver of this problem. The movement of hospitals to offload sapping requirements for their emergency departments to third party management companies. These hospitals very often make no requirements of these companies to ensure the staffing of the ED fit within the insurance networks that the hospitals have agreed to. As a result, a patient who does their homework ahead of time and rightly thinks they’re going to an in network hospital, received services from an out of network physician and a surprise medical bill follows.

  • 34:20 Frederick Isasi: Let me give you one real world example. Nicole Briggs from Morrison, Colorado outside of Denver. Nicole woke up in the middle of the night with intense stomach pain. She went to a freestanding ER. She was told she needed an emergency appendectomy. She went to a local hospital. She did her due diligence. Confirmed repeatedly that the hospital and its providers were in network. However, months later she received a surprise bill from the surgeon who ended up, was out of network. The bill to Nicole was $5,000. Nicole tried to work it out with her insurance company, but within two years, a collection agency representing the surgeon took her to court and won the full amount, including interest. As a result, a lien was placed on her home and the collection agency garnished her wages each month. This came right before Nicole was about to deliver a baby and go on maternity leave. And by the way, this investigation found that there were over 170 liens placed on people’s homes in the Denver area by emergency department physicians.

  • 38:05 Professor Jack Hoadley: Our research shows that today, 25 states have acted to protect consumers from surprise bills in at least some circumstances. Nine of these 25 meet our standards as offering what we consider to be comprehensive protection. For protections to be comprehensive, we look to number one, whether they apply in both emergency situations and an in-network hospital setting, such as electing an in-network surgeon, but being treated by another clinician who’s out of network. Second, that these laws apply to both HMO’s, PPO’s and all other types of insurance. Third, that the law does address both insurers by requiring them to hold consumer’s harmless from balanced bills and providers by barring them from sending balanced bills. And fourth, that the laws adopt some kind of a payment standard. Uh, either a rule to determine payment from insurance provider or an arbitration process to resolve payment disputes. Although these four conditions don’t guarantee complete protection for consumers, they combine to protect consumers in most emergency and network hospital settings that the states can address. But as you’ve already heard, state protections are limited by federal law, ERISA, which exempt states from state regulation’s, self insured, employer sponsored plans.

  • 43:30 Chairman Frederica Wilson (FL): Under current law, who is responsible for making sure that a doctor or a hospital is in-network? Is it the doctor, the insurance company or the patient themselves? Frederick Isasi: Uh, chairman Wilson, thank you for the question. To be very clear, it is the patient themselves that has a responsibility and these negotiations are very complex. These are some of the most important and intense negotiations in the healthcare sector between a payer and a provider. There is absolutely no visibility for a consumer to understand what’s going on there. And so the notion that a consumer would walk into an emergency department and know, for example, that their doctor was out of network because that hospital could not reach agreement on an in-network provider for the ED is absurd, right? There’s no way they would ever know that. And similarly, if you walk in and you received surgery and it turns out your anesthesiologist isn’t in-network, there’s no way for the consumer to know that. Um, and I would like to say there’s some discussion about transparency and creating, you know, sort of provider directories. We’ve tried to do that in many instances. And what we know is that right now the healthcare sector has no real way to provide real actual insight to consumers about who’s in-network, and who’s out of network. I would-probably everybody in this room has tried at some point to figure out if a doctor’s in-network and out of network and as we know that system doesn’t work. So this idea that consumers can do research and find out what’s happened behind the scenes in these very intensive negotiations is absurd and it doesn’t work.

  • 46:30 Professor Jack Hoadley: Provider directories can be notoriously inaccurate. One of the things that, even if they are accurate, that I’ve seen in my own family is you may be enrolled in Blue Cross-You ask your physician, "are they participating in Blue Cross? They say “yes”, but it turns out Blue Cross has a variety of different networks. This would be true of any insurance company, and so you know, you may be in this one particular flavor of the Blue Cross plan and your provider may not participate in that particular network.

  • 47:30 Christen Linke Young: Notice isn’t enough here. Even if a consumer had perfect information, which is not a reasonable expectation, but even if they did have perfect information, they can’t do anything with that information. They can’t go across town to get their anesthesia and then come back to the hospital. Um, their-even with perfect information, they may be treated by out of network providers. And so we need to set a standard that limits how much providers can be paid in these out of network scenarios that makes it sort of less attractive for providers to remain out of network. And so instead, they are subject to more normal market conditions.

  • 1:01:25 Rep. Phil Roe (TN): I’ve had my name in networks that I wasn’t in. That you-that you use, and many of those unscrupulous networks, will use that too to get people to sign up because this doctor, my doctor is in there when you’re really not.

  • 1:10:25 Frederick Isasi: Um, there is a concept here, which is, what does in network mean, right? When you sit down with your husband or your partner and decide what kind of insurance do we want for our kids, right? We want to make sure that they can go to the ED if they’re playing soccer, they get hurt, all those sorts of things. The question is when you make that decision and you say, "Oh, look, this hospital is in-network, right? But what does that mean? If you can go to that hospital and all the services they’re providing are out of network, right? And I think as you’ve said, and as we’ve heard from other folks, the patient is not the person who should be responsible for that. It’s the folks who are negotiating. It’s the hospital, it’s the doc’s and the payers that should bear that responsibility. So let’s start by clarifying what does in-network mean, so that we have some way of making educated decisions about the insurance that we’re purchasing and putting our trust in.

  • 1:29:30 Professor Jack Hoadley: There may be instances where consumers get bills sent to them, aren’t aware that they don’t need to pay them, so don’t start the process. And that goes to this sort of point of how do you really make sure it’s not the consumer’s responsibility to figure out that, oh, I don’t, by law, I don’t actually have to pay this bill. Now what do I do to make sure that happens? If you don’t know that, uh, that doesn’t really help you. And so what some other states like California has done, is to include a provision that says the provider really can’t send a bill and if they do end up sending a bill and the consumer pays it, there’s an obligation on that provider to refund the amount that was paid back to the consumer. And that’s something we haven’t seen in some of the other states.

  • 1:39:15 Rep. Joe Courtney (CT): ERISA really has to be dealt with if we’re going to really have a comprehensive solution for America’s patients. Is that correct? Ilyse Schuman: That’s exactly right. Um, for the self funded plan too 60% of employer based plans that are not subject to these state laws, like in Connecticut or other states, we have to have a federal solution that addresses ERISA, so that we deal with this problem in a uniform nationwide way.

Documentary: This is a clip from the documentary: 911, Toxic Legacy which aired on Canadian CBC 9/10.2006, September 10, 2006

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Music Presented in This Episode

Intro & Exit: Tired of Being Lied To by David Ippolito (found on Music Alley by mevio)