Here’s the basic problem: As Vox and others have reported, in-network emergency rooms are often staffed by out-of-network doctors. This can lead to hefty bills for patients who think their providers are covered.
One patient I wrote about, for example, ended up with a $7,924 bill for emergency jaw surgery even though he was seen at an in-network hospital. The surgeon who saw him, it turns out, wasn’t in-network with the patient’s health plan.
As these surprise bills have gotten more media attention, both Sens. Maggie Hassan (D-NH) and Bill Cassidy (R-LA) have released bills to end surprise charges like that one. Now, the American College of Emergency Physicians — which represents emergency room doctors — is releasing its own six-point plan on how to tackle the issue.
The ACEP proposal is not quite as fleshed out as the Senate bills that already exist, but it shares some common elements with what is already floating around Congress. It gives a good sense of how doctors themselves would like to see the issue resolved.
It also suggests emergency doctors are expecting some kind of action on this issue in the near future — and wanted to lay down a marker about the type of proposals they’d support if Congress decides to take action.
Like the Hassan and Cassidy bills, the emergency physicians agree that patients should not be put in the middle of what is essentially a dispute between a doctor and an insurance company that can’t agree on the price of providing emergency care.
Instead, the emergency doctors are now suggesting that the doctor and the insurer should go to an impartial arbiter, one who will look over what each side thinks is a fair price and select one as the payment amount. This is somewhat similar to a state-level law that already exists in New York and has worked quite well to tackle surprise bills. It also looks a lot like the arbitration process that Sen. Hassan suggests in her bill, too. A lot of experts in surprise billing think this arbitration process works really well because it encourages each side to set reasonable prices, in the hope of the arbiter siding with them.
There are some other provisions in this bill, however, that are a bit different — and generally, more favorable to doctors (no surprise, given that this is the proposal coming from doctors). For example, this proposal says that for medical bills under $750, the arbitration process I discussed above won’t be followed — the insurer will just be required to pay those smaller charges.
ACEP, however, notes that other, state-level surprise billing laws provide a similar feature of having small bills paid automatically in order to avoid an overwhelming amount of arbitration.
This plan would also require that insurance plans send doctors whatever payment is necessary to cover a patient’s copayments and deductibles, and then turn around and collect those fees from the patients. This is pretty different from how medical billing works right now.
For example, when I go to a doctor’s appointment this afternoon, I’m going to pay a $50 copay to his office directly. They’ll let my insurance know that my copay has been paid — or, if I don’t pay it, send me a bill for what I owe.
But the emergency doctors want to get out of the bill collection business. Under their plan, I would not pay them a copay when I turned up in their emergency department. Instead, my insurance plan would pay it for me — and then turn around and collect the fee that I now owed them.
The emergency doctors say this is all about streamlining to make things simpler for the patient. “This ensures patients only have a single point of contact for emergency medical billing and payment, and will no longer receive and have to reconcile multiple, confusing bills and EOBs that result from the many providers that are often involved in a single emergency episode,” they argue.
At the same time, emergency doctors obviously know that patients get frustrated with whoever is sending out the bills. And this change would essentially have insurers sending out more emergency room bills, and doctors sending out fewer. And as to whether this is streamlining? It doesn’t quite look like that, when you’re inventing a new system that has insurers paying doctors and then insurers chasing down copayment for the doctors, instead of patients just making their copayments directly.