By Sunny Jha, MD, MS, and Linda Hertzberg, MD, FASA
It is hard being an anesthesiologist these days without seeing the words out-of- network billing pop up in an email or news website. But what exactly does this mean and why is it important?
Out-of-network billing, also called surprise billing, occurs when a patient receives a bill from a physician whose services are not covered by their healthcare insurance company. The “surprise” is because patients have no idea the physician is not in their insurance network nor did they necessarily choose that specific physician. For example, if a patient undergoes a procedure by a surgeon who is in-network (i.e. covered by a patient’s insurance) and the anesthesiologist happens to be out-of-network, then that patient will receive a “surprise bill” for the anesthesiologist’s services since the insurance company is not contractually obligated to cover the care provided by the anesthesiologist.
The difference between the sticker price for medical services and what is actually paid by insurance companies to its contracted providers is generally very significant. Unfortunately, the patient likely receives some iteration of the sticker price and not the negotiated price. This, more often than not, is quite a traumatic experience for patients who are then held liable to cover the cost for that care. However, under “balanced billing”, the insurance carrier may agree to cover a portion of the costs billed by this out-of-network provider, but then the obligation for the rest, which may still be quite substantial, lies on the patient.
Over 90 percent of anesthesiologists bill in-network; therefore, many of our patients are protected from surprise out-of-network bills.[1 However, for the few patients who do receive them, the consequences can be disastrous. Our ASA and CSA are both committed to helping patients avoid this and have been working on the state and national level to address this issue. Our societies broadly support policies that:
1. Hold patients harmless of unanticipated medical bills
2. Ensure enforceable network standards as an essential part of
fixing this problem
3. Identify fair solutions to ensure appropriate payments to providers
4. Utilize an independent dispute resolution system to resolve
disputes between physicians and insurance companies
At the federal level, several bills have been introduced to “fix” surprise billing.
The AMA, ASA and a plethora of other medical societies have endorsed the “Protecting People from Surprise Medical Bills Act HR 3502” introduced by our own California Congressman and Emergency Medicine Physician, Raul Ruiz. This Act hopes to replicate the successful New York state solution on a national level by offering robust patient protections and removing patients from billing disputes. The New York state model has been in place since 2015 and has reduced complaints related to surprise bills while also saving health care dollars. The legislation includes payment to providers at a "commercially reasonable rate" based on criteria agreed upon by physicians and insurance companies, and the creation of an independent dispute resolution system utilizing a “baseball style” of arbitration.
“The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills. The proposal doesn’t pick winners or losers but instead places the dispute where it should be - between the health care provider and the insurance company,” said ASA President Linda Mason, M.D., FASA. “I’m also pleased this proposal helps patients by providing greater transparency of their in-network providers while ensuring an independent dispute resolution system to resolve billing disputes.” The ASA is encouraging members to contact their Congressional representatives to support this bill (https://asahq.quorum.us/campaign/21221/).
On the Senate side, “The Lower Health Care Costs Act S. 1895” has made it out of the Health, Education, Labor and Pensions (HELP) Committee for further consideration. The ASA, and much of organized medicine, has decided to oppose this Act for several reasons including payment caps from insurers to physicians and its creating mechanisms for resolving disputes that would disproportionately benefit insurance companies. The ASA is urging members to call their Senate representatives and express your opposition to this Act. (https://asahq.quorum.us/campaign/21149/). Senator Bill Cassidy has also written a resolution which has some fundamental aspects we support, such as the baseball style arbitration dispute resolution process as present in the New York model. However, Senator Cassidy’s resolution does not appear to be gaining much traction in the Senate.
It is critical for all anesthesiologists to be engaged and participate in grassroots advocacy. The out-of-network billing Acts proposed by Congress have the potential to rewrite the way anesthesiologists are compensated and require our full attention. Please contact your Congressional representatives as soon as possible. Also, please share https://www.outofthemiddle.org with your friends, family, colleagues and on your social media platforms. The website is a partnership between several medical societies and enables our patients to have a voice in this fight. It is only with your help can we ensure our patients are protected from out-of-network billing.
Please watch for additional communications from CSA informing you how you can engage on this critical issue – whether you are a member of ASA’s Team 535, a network of established key contacts, or an individual member – your voice is relevant and required!
ASA also gave an update on the legislation this morning - you can read it here.
Dr. Linda Hertzberg is the ASA Director from California and Dr. Sunny Jha is chair of CSA’s Legislative Affairs Committee.
 Kennedy, Kevin et al. Surprise out-of-network medical bills during in-network hospital admissions varied by state and medical specialty, 2016. March 28, 2019. https://bit.ly/2HKc46U