January 1, 2022 was an important day for Americans. In one of the few outright victories for American consumers in recent memory, federal legislation banning “surprise medical billing” has come into effect.
Anyone who has had a brushing in the emergency room or hospital care has probably been subjected to this practice. Although the hospital you are in may be considered an “approved, networked” facility depending on your health insurance, the various doctors and specialists you see inside the hospital may not be. and you wouldn’t know it. And if these professionals are not part of your network, they were entitled to “bill” you, that is to say to bill you the difference between what your insurance paid them and what they claim to be. from. Americans often owed thousands or even tens of thousands of dollars in balance billing, which has become a serious risk factor for bankruptcy.
Insidiously, it’s often when you’re least able to protest that such surprise bills do occur. Emergency room doctors are almost always off-grid doctors, but you wouldn’t see an ER doctor unless you had no other choice. (I once walked out of an emergency room when they refused – refused! – to tell me whether the ER doctor was in my network or not.) Specialists who review your x-rays or give you an anesthesia may not be in your network – and they may be doctors you’ve never seen or interacted with; you might not be aware of their involvement in your care until the bills start showing up.
The United States Congress, to its surprising credit, has legislated this issue for Americans as a 2022 New Year’s Eve gift. You, the consumer, will no longer receive a “balance sheet” for being processed in a networked facility by an outside professional. network. You will pay your usual co-payments and deductibles, but the trader and the insurance company will then have to arbitrate a price that the insurance company will pay. The good news is that such arbitrage can push prices further towards an acceptable average price level, thereby slowing the rise in insurance premiums. It will also encourage professionals whose business models were based on predatory billing, such as some emergency physicians, to join insurance networks.
Of course, the law is not perfect. There has never been a bill passed by Congress that has not been problematic. The main problem with the new legislation is that, although almost all forms of medical care are included, there is one glaring exception: ground ambulances. (Air ambulances are covered by the new legislation, without justification.) Land ambulances can still “balance” you despite the new law and the average cost of a land ambulance ride – which you will most likely pay out of pocket via your co-payment / deductible plus the balance bill – is approximately $ 1,200 per patient transported. In Texas where I live, 85% of ambulance trips are off-grid; in Houston, 100% are.
And there is no shortage of horror stories. A reader’s comments on a recent New York Times article, for example, run the gamut: ambulance bills of up to $ 4,000, double billing for an ambulance, and unnecessary fire truck shipping. , a gym goer getting slapped with a bill after injuring himself and having an ambulance called due to gym ‘politics’. Here we go.
We live in a strange country if the first thing that comes out of the mouth of an injured person is, “Don’t call the ambulance! but it is an obvious temptation for people who know that paying thousands of dollars for a short trip to the hospital is a real possibility.
Some states – Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont, and West Virginia – have been working proactively to close the loophole regarding surprise land ambulance billing. A few of these states exempt publicly funded ambulance services from their consumer protections, but most do not. In Colorado and Maine, for example, state regulators stepped in and decided on “reasonable and customary” rates for ground ambulance service after listening to a range of stakeholders. Insurance companies would have to bear these rates when negotiating with suppliers, and ambulance companies could not balance the bill beyond them.
Utah lawmakers can use this upcoming legislative session to fill that gap as the federal government convenes its myriad committees to discuss the matter. Ten states are proposing model legislation that Utah could adapt and pass. It would be a huge boon to the people of Utah and could be offered this very year.
Valerie M. Hudson is Professor Emeritus in the Bush School of Government and Public Service at Texas A&M University. His opinions are his.