Nobody wants to end up in the hospital or at the emergency room, whether for a routine procedure or unplanned care. It’s a stressful, harrowing experience for patients and their families alike.
Thanks to an unfair practice known as “surprise medical billing,” the pain doesn’t end when patients are released. It can continue for weeks and months afterward as sky-high medical bills for the cost of care patients thought would be covered by insurance.
As someone who has firsthand experience with surprise billing, I can attest that it is a real problem, one that Congress must solve the right way.
After retiring as an employee of the city of Fayetteville, most recently as its assistant city manager, I obtained new insurance through my wife’s company. With my diagnosis of younger-onset Alzheimer’s disease, my neurologist recommended that I begin biweekly sessions for occupational and physical therapy.
I was soon shocked to receive a bill of more than $1,000 for only two visits to Duke Hospital, instead of a $20 co-pay for an “in-network” visit. This is far from the kind of “surprise” any patient going through treatment needs.
Most patients don’t know how to navigate our extremely complex health care system and, like me, are left with extremely high medical bills when they receive out-of-network care with or without their knowledge. This was never explained to me, and, as a new retiree on a fixed income, it’s unacceptable.
It’s hard enough to deal with health concerns as it is; surprise billing only adds more stress, pain and misery.
Fortunately, Congress is finally working to address this important issue. As it does, members must ensure that whatever solution they enact is the most effective, least intrusive one possible. Some of the proposed solutions do a better job of that than others.
Some of the legislative answers to surprise medical billing would attempt to protect patients by calling for a government-mandated benchmarking approach, which basically would put federal government bureaucrats in charge of determining the rates paid to physicians for performing out-of-network care here in North Carolina and across the country. Giving the government greater control over our health care is a treacherous road.
Government benchmarking would end up underpaying many doctors for the care they provide by setting artificially lower rates that ignore the differences in cost for providing clinical services in different regions and types of facilities.
That could end up costing local hospitals, emergency rooms and other health care centers hundreds of millions — if not billions — of dollars. This would be especially detrimental to North Carolina’s many rural hospitals, which already struggle just to keep their doors open and keep serving our communities.
Ultimately, patients would be stuck with the short end of the stick yet again. The financial toll this approach would take could end up forcing many hospitals to consolidate or close altogether.
There are, however, more practical solutions being considered in Congress — ones that would implement independent dispute resolution, or IDR, to resolve payment disputes between health care providers and insurers.
IDR would facilitate a fairer negotiation process that allows both sides to submit their desired payment amounts. An impartial, third-party mediator would ultimately decide the amount on a case-by-case basis, ensuring that doctors are paid fairly while providing financial security for rural hospitals in particular.
IDR has already proven effective in New York, which adopted it in 2015 to protect patients from surprise billing. There, it has lowered out-of-network rates, increased in-network participation and helped keep costs for emergency care stable. This is the solution Congress should seek to replicate on a national scale.
North Carolina’s U.S. senators, Richard Burr and Thom Tillis, should help ensure that whatever bill Congress passes includes the IDR framework — and not the harmful, government-mandated benchmarking approach — so we can fix the surprise billing problem before it harms more patients in North Carolina and across the country.