Almost everyone agrees that surprise medical bills—charges from doctors that patients cannot reasonably expect—are abhorrent and should be restricted. But, because of special-interest infighting pitting insurers and consumer advocates against physicians and private equity firms, Congress has serially failed to ban this rapacious practice, which can drown patients in unanticipated medical debt. Now a narrow window of opportunity has opened. Senate Majority Leader Mitch McConnell must join with other congressional leaders to get surprise medical billing reform into the big year-end government funding package lawmakers are crafting.
When people go to a hospital in their insurance network, they have every reason to expect that the doctors who treat them will bill accordingly. But sometimes they do not. Your surgeon might be in-network, but the anesthesiologist sedating you or the radiologist reviewing your X-rays might not have negotiated a relationship with your insurance company, and they often charge far more for their services than in-network providers. In that case, they bill the patient the amount the patient’s insurance company refuses to pay them.
Lawmakers appeared to have a bipartisan fix a year ago, but it stalled after intense lobbying from physicians’ groups. Last Friday, however, key legislators united behind a new compromise plan. The proposal would bar doctors from sending patients these sorts of bills in most circumstances. Instead, insurance companies would pay. The sticking point has been how to determine the price. The negotiators decided on an arbitration process between insurers and providers, which resembles the process that doctors’ groups wanted. But the arbiters would be guided by the median in-network rates for the services covered, which resembles the price-benchmarking approach that consumer advocates favored.
The plan is not perfect. It would be simpler and cut costs more if lawmakers just required every provider working at an in-network facility to be in-network themselves, rather than relying on arbitration to set prices. But the proposal would still represent a massive improvement on the status quo, saving consumers lots of money without punishing doctors who charge reasonable rates. Though the plan covers air ambulances, which can cost tens of thousands of dollars, it does not cover ground ambulance services, which are a major source of unexpected medical bills. But future legislation can address this gap.