Legislative Update: March/April 2020

Legislative Update: March/April 2020

Have You Ever Received a Surprise Medical Bill?

By Shannon Benton, Executive Director

It happens all too often.  Out - of - the - blue you get a gut-wrenchingly high medical bill for services that you thought were covered by Medicare.  Congress recently took the first step to deal with the practice.  Legislation is advancing in the House that would protect patients from surprise medical bills and set up the process by which health plans and providers would settle disputed billing amounts.

Surprise medical bills often occur when a patient is treated by an “out-of-network” provider, which can sometimes happen even at an “in-network” facility.  This problem occurs with the greatest frequency to enrollees of Medicare Advantage plans.  The plans have contracts with a network of preferred doctors, hospitals and other providers to control costs for patients.  Out - of - network providers mean patients get stuck with extra out – out- of – pocket costs.  Sometimes a lot extra.

The problem can also affect beneficiaries who are covered by traditional fee-for-service Medicare and a Medicare supplement when the patient is seen by a provider who does not have a contract to provide services under Medicare.  But since 90% of doctors do accept traditional Medicare, this is less likely.

Surprise medical bills are generally the difference between the amount that the provider charges, and the negotiated amount that the private insurer typically pays for the service(s).  A large majority of Medicare beneficiaries (85%) think healthcare providers should be restricted from this billing practice.  Surprise medical bills affect not only Medicare beneficiaries, but patients of all ages with private insurance.  The patients who are most vulnerable to these unexpected bills include those who need ambulance or emergency room services.  Often, the bills come from doctors the patient never remembers seeing.

Surprise medical bills are not only growing in the frequency with which they occur, but also in the cost of services provided, leaving unsuspecting patients responsible for bills in the hundreds, or even thousands, of dollars.

The bipartisan deal that was reached in the House last year would ban providers from sending surprise bills and would require insurers to pay them.  Opponents argue this opens the door to rate setting or federal “price controls.”  But the actual costs in question are currently those directly negotiated by healthcare providers and private insurers, and not by Medicare.

Medicare does not reimburse Medicare Advantage plans the same way it does for traditional Medicare.  Plans receive a per- person payment to provide all Medicare covered services, rather than a fee for each service.  Critics of Medicare Advantage point out that, due to this system of payment, private plans have an incentive to shift a bigger share of the cost to patients to boost profits.

TSCL strongly supports legislation to end surprise medical bills and is continuing to work for enactment of the bills in the House and Senate.  We encourage you to email your Members of Congress and ask your lawmakers to support this legislation that would prohibit this practice and leave you stuck with the bills.