What Is It?
Surprise medical billing is a term to describe a bill for an out-of-network service that a patient gets after going to an in-network provider where the patient receives a service from an out-of-network subcontractor. I’ll give you an example:
You’ve broken your ankle and need surgery to repair it. You research ankle surgeons and choose a provider and a facility that are in your health care network to avoid paying high out-of-network charges. After surgery, your bills start coming in and many of them are what you expect with insurance paying a portion of the surgery cost. But you also get an extremely high bill from the anesthesiologist. This provider’s charges are out-of-network and not covered at all by your health plan.
That’s surprise medical billing. Even though you’ve made every effort to avoid out-of-network charges, you’re still responsible for these fees. And because it’s out-of-network, your health plan may have no obligation to pay a dime. It’s also important to know that these fees can be exorbitant, charging 400% or more of the Medicare benchmark rate in some cases.
Surprise medical billing is an egregious practice, but I have good news. The Church Alliance, of which I am vice chair, along with the American Benefits Council, has successfully worked with Congress to pass legislation that will end surprise medical billing.
After two years of advocacy work, this important legislation was passed into law in December 2020 and will take effect January 2022. The legislation will effectively put a stop to patients being charged out-of-network rates by providers at an in-network facility.
What It Means For Employers
While this is a big win for patients, it’s not a perfect solution. As with most legislation, this bill went through a series of negotiations. The result is that instead of the patient receiving the surprise bill, it will go to the health plan provider. By shifting the cost to the health plan providers, we may see those providers in turn shift the burden to employers in the form of higher rates.
To that end, I have good news for Portico’s health plan members and those considering a Portico health plan. Because we have never allowed our health plan members to be subject to surprise medical billing, the employers we cover will not see any cost shifting due to this new policy – simply because it’s always been our policy.
If you’re an employer not covered by Portico’s health plan, there are important steps you can take to be ready for this new legislation. As you’re thinking about health plan renewals for 2022, you should ask your health plan provider the following questions:
“How will you respond to or accommodate this new legislation? How will it impact the health plan? How will it impact our rates? Are we going to end up paying higher rates because more of those surprise costs will be shifted?”
By understanding your health plan provider’s preparedness for this legislation, you can make a more informed decision regarding your coverage.
What It Means For Individuals
If you’re an individual not currently covered by Portico’s health plan, know that until this legislation is enacted in 2022, you could still be impacted by surprise medical billing. Be sure to ask your health care providers up front for details about all ancillary services needed. Services like radiology, anesthesiology, and pathology are some of the top offenders for surprise medical billing, so you’ll want to understand whether or not the providers of these services are covered under your health plan.
Enhancing Lives. Strengthening Ministry.
Portico’s vision statement is “Enhancing Lives. Strengthening Ministry.” I see us living out this vision through our advocacy work in ending surprise medical billing. Helping people receive high-quality medical care without incurring debilitating medical bills certainly enhances lives. It also strengthens ministry because every dollar that’s not spent on a medical claim – especially an outrageous one – is a dollar available for more ministry.