Congress May Have a Cure for Surprise Medical Bills

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Relief may be in sight for the millions of Americans on the hook every year for bills their health insurance won’t cover, if federal legislation to curb surprise medical bills becomes a reality.

Key committees in the U.S. House of Representatives and Senate have previously approved separate bills and are now working on compromise legislation they hope to attach to a spending package that Congress could vote on in December. President Donald Trump has signaled his support.

Surprise medical bills are a side effect of receiving medical care from a doctor or hospital not in your insurance network. This often happens in emergency situations, as Emily Roberts of La Costa, Calif., discovered this summer. Her 12-year-old son fractured his arm on a camping trip in the mountains and had to be flown to the hospital by an out-of-network air ambulance, leaving her with a bill for $56,000. 

But it can also happen even when you take every possible step in advance to make sure your providers take your insurance. Before Anna Petrie of New Britain, Conn., had a procedure to treat kidney stones a couple of years ago, she confirmed that the hospital and doctor treating her were in-network and even got a preapproval letter from her insurer. But she still got a bill for $2,500—the machine used during the procedure to break up the stones, it turned out, wasn’t covered.

Four in 10 adults under 65 with health insurance say they’ve gotten a surprise medical bill in the past year, and two-thirds of Americans say they’re worried about being able to afford their own or a family member’s unexpected medical bills, according to an analysis by the nonprofit Peterson Center on Healthcare and the Kaiser Family Foundation, a nonpartisan health policy research group.

“People are really getting hurt,” says Karen Pollitz, a senior fellow at KFF. “The bill can be for tens of thousands of dollars.” 

A KFF poll in September found that more than three-quarters of Democrats, Republicans, and independents say protecting people from surprise medical bills should be a top priority for lawmakers. But the proposed legislation faces hurdles from insurers, hospitals, and doctors, who want different solutions to the surprise medical billing problem, says Jack Hoadley, a healthcare policy expert and research professor emeritus at Georgetown University’s Health Policy Institute in Washington, D.C. He says those groups are all actively lobbying lawmakers for the solutions they favor.

Health insurers and employers that offer insurance to workers want to cap the amount that insurers have to pay doctors for disputed out-of-network charges. Healthcare providers and hospitals want payment disagreements to be settled by third-party arbitrators and don’t want the amount they charge to be limited.

Until the legislation is settled, there’s a chance that competing interests could water down the bills’ consumer protections. And if Congress doesn’t act by December, the legislation could be back-burnered because next year is likely to be dominated by the presidential election.

The stakes for consumers are high, says Dena Mendelsohn, senior policy counsel at Consumer Reports. “If Congress fails to act, no matter how diligent a consumer is in getting insured and researching their provider network, a crippling surprise bill could be right around the corner.” 

What Could Change for Consumers

The House and Senate bills, which are largely similar, would dramatically change what happens when consumers get an out-of-network medical bill, Hoadley says. The Lower Health Care Costs Act in the Senate and No Surprises Act in the House both:

Cover a wide range of situations. Protections would apply to out-of-network bills in all medical emergencies as well as in non-emergency situations when, without your knowledge, you are given treatment your insurance doesn’t cover or are seen by an out-of-network provider. An average of 18 percent of emergency room visits and 16 percent of care at in-network facilities now result in at least one out-of-network bill. And those charges are, on average, two to three times higher than in-network ones.

Ban balance billing. No out-of-network provider would be able to bill you for the balance your insurer won’t pay. You would only pay the copays, deductibles, and other charges you would have paid if you were treated in-network, not the difference between what a doctor bills and what the insurer says it will cover.

Take consumers out of the middle. When there is a dispute about a bill, the health insurer and healthcare provider would have to deal directly with each other. Currently, the patient has to resolve the billing problem, which can take multiple calls to the insurer and provider and months to sort out, if it ever can be. One difference between the two bills: In the House but not the Senate version, disagreements about bills over $1,250 could be settled in independent third-party arbitration and the amount of the out-of-network charge, not just the in-network rate, could be considered. This could result in substantially higher charges, a cost consumers are likely to bear in the form of higher premiums down the road.

Apply to most health insurance plans. Although 28 states have passed surprise medical bill laws with varying degrees of protection for consumers, most people get health insurance through group or employer plans that are exempt from state laws. Under the House and Senate bills, protections would cover you in all 50 states no matter how you get your insurance. (Medicare participants are already shielded from surprise medical bills because federal law limits what providers who take it can charge.)

Limit air ambulance bills. Only the Senate version covers out-of-network air ambulance bills like the $56,000 one that the Roberts family faces. The House only requires air ambulance bills to show charges for air transport separately from the cost of emergency medical supplies. Neither bill applies to ground ambulances, even though they are one of the most frequent reasons for surprise medical bills. In fact, from 2010 to 2016, 86 percent of emergency department visits and 82 percent of inpatient admissions requiring a ground ambulance resulted in an out-of-network bill, according to an analysis by researchers at Stanford University in California. Pollitz, at the Kaiser Family Foundation, says the issue is complex to legislate because ground ambulances are operated by a range of providers, from local municipalities and nonprofits to hospitals and private companies, and charges vary widely around the U.S. 

“This is a unique opportunity for Congress to both protect individual consumers from shocking surprise medical bills today and shield all of us from excessive charges that threaten to make health insurance unaffordable tomorrow,” says CR’s Mendelsohn.

How to Fight a Surprise Medical Bill

In the absence of a comprehensive federal law, here’s what you can try to do to prevent an unexpected medical bill or fight one that comes your way.

• Understand what your insurance covers. Reviewing your insurance policy isn’t fun, but it’s a necessary step. Ask your insurer for documentation on what the plan will and won’t cover if you need emergency care and how much you’ll pay if you go out of network. In most cases your insurer is required to pay for reasonable medical expenses no matter where you’re treated if you go out of network in an emergency situation. If you’re in a car accident, for example, and taken to a hospital outside your network, your insurer will still cover the expense. But there’s no concrete definition of what is and is not an emergency, and some insurers will deny claims they don’t think constitutes one. So know ahead of time how your insurer defines emergencies.

• Talk to your doctor. Tell him or her which insurance you have and, if you need a specialist, ask to be referred only to other doctors in your network. Same thing if you need lab tests and services such as MRIs. If you’re having elective surgery, you may have to do some of this legwork yourself—for example, by finding out whether all those who will be involved in your care, such as an anesthesiologist, are in your network. Simply put: It is never safe to assume that a provider or lab at an in-network hospital is itself in your network.

• Know your rights. Check to see whether your state has laws protecting against surprise medical bills. The Commonwealth Fund keeps track of these state efforts. But there’s a lot of change happening on the state level, so check with your state insurance regulator to find out the latest specifics. You can look up your state insurance regulator through the National Association of Insurance Commissioners.

• Fight the bill. If you get an out-of-network bill, contact your insurer first to see whether it’s a mistake. If it’s not, ask whether the insurer will cover the bill. If it won’t, try to negotiate the charge with the doctor or hospital. If that fails, file an appeal with your insurance company. For more information on how to file an appeal, use this free guide from the Patient Advocate Foundation, which includes sample appeal letters. You should also report the problem to your state insurance regulator or state attorney general and mention that in your appeal letter. To find out how to file health insurance complaints in your state and to share your story, go to Consumer Reports’ End Surprise Medical Bills site. 

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