Article: A provider's perspective on the surprise medical billing debate

By Dr. Michael Simon

On the issue of surprise medical billing, much of the reporting has focused on the issue from a one-sided perspective. The provider perspective is often left out, or worse, presented in a negative light. Instead of reporting that looks at the solutions proposed by physicians and insurance companies, the public has been presented insurer-favorable coverage that dismisses the voices of physicians and their concerns for patients across the country.

It is important that the public clearly understands the principles behind provider solutions. First and foremost is to hold patients harmless. But it's also about increasing transparency and promoting strong provider networks as well as ensuring that patients continue to have access to the highest quality of care.

Articles to date shed light on various bills currently before Congress but often omit facts. The current proposals in the House and Senate are structured to benefit insurance companies. When one dissects the specifics of the bills, they set payments at a "median in-network rate." This is a rate set by insurers and designed to eliminate the ability for providers to negotiate. Some articles mentioned that additional language to allow arbitration was added to one of the bills, implying that this should make providers happy. What's omitted is that the arbitration is only for amounts over $1,250, which excludes nearly all of emergency room services and anesthesia. In addition, the guidelines for arbitrators include median in-network rates. This is a windfall for insurance companies. Moreover, is this what is best for patients?

There are state laws already in place that meet providers' principles: hold patients harmless, increase transparency, strengthen provider networks and ensure high-quality care. The two key ones are in New York and Texas. The New York law, with over five years' experience, has enabled patients to enjoy adequate access, kept insurance premiums in check, given providers the ability to negotiate and held insurers accountable. This should be the standard for a fair law. Instead, insurer-favorable constructions like those proposed by Reps. Frank Pallone (D-N.J.) and Greg Walden (R-Ore.) and Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are used as the standard.

In the latest turn of events, the media has criticized the amount of money spent educating and lobbying on behalf of providers, without mentioning the insurance company lobby. Insurance company profits remain high while provider payments decrease, patient co-pays and deductibles skyrocket, and networks narrow to unacceptable levels.

Most important, people need to be informed about the ill effects some of this legislation will have on the healthcare system and patients' access to care. As we saw in California, a law that allows unilateral rate setting by insurers eliminates the incentive for insurers to contract with providers; instead, they adopt a "take it or leave it" mentality where patients suffer, losing their access to hospitals and physicians. Meanwhile, insurers say they have plenty of doctors and hospitals on their panels and in their networks; however, you'll find that access is only for those in their top-tier plans. The average patient will see diminished access.

The greater truth here is that the real potential winners in this debacle are the insurance companies, and the potential losers are patients. Yes, new federal legislation should remove patients from the middle of the debate while giving providers a mechanism to negotiate with insurers. An independent dispute resolution mechanism would ensure fair and equitable treatment for all, and that is what's best for patients.