Principles to Address Unanticipated Medical Bills

Solutions that remove patients from billing disputes and ensure access to quality specialty care

In recent years, insurers have created products with narrow, inadequate and non-transparent provider networks. While most plans offer access to primary care services, access to specialty care is often limited by the insurer in an effort to drive profit through reduced costs. Limited access to in-network providers requires patients to receive medically necessary care out-of-network.

Many of these plans also offer low monthly premiums in exchange for high annual deductibles. For a healthy individual, this is appealing due to low upfront costs. However, in emergencies or for patients with chronic illnesses, reaching a $10,000 deductible, for example, will require significant out-of-pocket costs before the patient's insurance plan starts to financially contribute to care. Once patients reach their deductible, many plans still require coinsurance payments.

Unfortunately, patients rarely understand these terms, let alone how they will be charged for their cost-sharing responsibilities. It's no wonder patients are "surprised" when they are directly billed for care that they thought their insurance policy would cover. This is a direct result of the failure by insurance companies to educate patients about the limitations of their policy. The American Society of Plastic Surgeons supports state and federal efforts to protect patients who receive unanticipated medical bills. This can only be achieved through a comprehensive solution that safeguards patient access to necessary specialty care through provisions which:

• Remove patients from billing disputes for out-of-network emergency care by automatically assigning the patient's benefits to the physician. Patients should only be responsible for their in-network cost-sharing amount, while allowing the provider and carrier to directly negotiate appropriate reimbursement for the remaining expenses
• Ensure patient choice by permitting patients to knowingly select non-urgent out-of-network care, as long as written consent is provided and the patient understands their full financial responsibility
• Facilitate a fair contract environment between providers and insurance carriers that encourages both parties to negotiate appropriate payment. This is only possible if the minimum benefits standard for out-of-network services is based on billed charges that reflect the market value of services and not a percentage of Medicare or allowed amounts as dictated by the insurance carrier
• Provide fair and timely payment by requiring insurance plans to reimburse providers for unanticipated and/or emergency out-of-network care based on a percentile of physician submitted claims collected by an independent, non-profit database
• Mandate adequate insurance networks and reduce maximum allowable cost-sharing amounts
• Address existing state policies and ensure coverage of ERISA plans by establishing a baseline standard that protects patients and providers across all 50 states