Millions of people with comprehensive health care coverage are susceptible to unexpected out-of-network bills that can amount to thousands of dollars, according to a new report from the Kaiser Family Foundation.
Study researchers followed 19 million people in 2017, excluding patients 65 and older, and estimated that on average nationwide, 18% of emergency room visits and 16% of hospitalizations trigger a surprise bill for patients who have health insurance through a large employer. Even if an insured patient visits the emergency department at an in-network hospital, the physicians on duty may not have a contract with the insurer. In addition, there are no guarantees that an entire surgical team at a hospital is in-network, even for scheduled procedures.
The report also found that the likelihood of a patient receiving an unexpected bill varies markedly on his or her home state. Individuals in Minnesota had the lowest odds of receiving a surprise bill (2% of emergency room visits and 3% of in-network hospitalizations), while patients in Texas had the highest odds, at 27% and 38%, respectively. The disparity seems to be related to the breadth and design of hospital and physician networks in each state.
Although some states have surprise billing protections, the need for federal oversight is evident. "This is a prominent problem affecting patients, and it is beyond the reach of state laws to fix, and it is, by definition, beyond the ability of patients to fix on their own," said Kaiser researcher Karen Pollitz.
A bill from Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA), soon to go before the Senate Health, Education, Labor and Pensions committee for a vote, would cap the amount patients can be charged to the cost of their in-network deductibles and copays. Instead, insurers would have to pay out-of-network doctors and hospitals the median rate paid to in-network providers, despite a battle already underway between insurers and employers who favor the bill and hospitals and doctors who want disputed bills to go to arbitration.
President Donald Trump said he would sign the legislation, which also promotes competition in the prescription drug market, blocks price bidding practices, and requires greater pricing transparency.