Dr. Howie Mell: How to treat surprise medical bills

By Dr. Howie Mell, Guest columnist

Mar. 2, 2020 in Winston Salem Journal

In the last few years, story after story has surfaced of patients receiving life-saving treatment, only to be sent a massive, unexpected bill in the mail. “Surprise medical bills” have overtaken the news cycle as the latest symptom of the flawed American health system. These bills, however, are not new, nor are they easy to solve.

As an emergency medicine physician who has been serving patients for 13 years, I’ve become well-versed in the complexities and challenges that gave rise to this pressing issue. With legislation making its way through Congress that aims to prevent surprise medical bills, it’s critical that policymakers target the source of the problem.

Over the past decade, insurance companies have increasingly offered “skinny” health plans with higher deductibles and fewer in-network doctors. These plans appear affordable to patients yet leave them exposed in the event of an emergency.

Thanks to these high deductible, narrow network health plans, patients, like those I’ve served for years, have been forced to cope with a proliferation of insurance denials related to out-of-network care.

In the emergency room, we’re committed to treating every patient, regardless of their insurance status. This includes patients who are out-of-network, uninsured, or underinsured.

In or out of the emergency department, patients should be confident that their insurance will cover them financially when they need care. The current system, however, endangers them in more ways than one.

When doctors or hospitals perform a costly procedure and are not adequately reimbursed by insurers, they risk closing their doors to patients in need. In Illinois, two hospitals have closed in 2019 alone. This unfortunate reality serves as a microcosm of the situation around the country, where rural hospital closures are increasing at an alarming rate. Like any business, it’s imperative that hospitals, and the emergency rooms they operate, can collect enough payments to continue providing top-notch, reliable care in communities across the country.

As someone who has seen the detrimental impact of low reimbursement rates, I can say that the current proposals in Congress, including rate-setting, will lead to fewer in-network practitioners, worsen the projected physician shortage in this country, and lead to even more hospital closures.

Just look at California, where a similar rate-setting measure was passed. Insurers have cancelled long-standing contracts and specialists have dropped from the on-call list, limiting options available to patients.

If Congress passes legislation setting reimbursements at the “median in-network” rate, the Congressional Budget Office projects a nationwide 20 percent cut in physician reimbursements following care.

Sadly, this legislation is the latest tactic by insurance companies to “win” payment negotiations with physician groups by rigging the system in their favor. Except this time, they are putting entire communities at risk by forcing hospitals to close their doors on patients in need.

Luckily, there is an alternative. A comprehensive independent dispute resolution (IDR) process, like those implemented in New York and Texas, protects patients and doctors, while keeping premiums steady. IDR establishes a process by which out-of-network claims can be adjudicated and an independent third party can decide what is a fair price when insurers and doctors are unable to reach an agreement.

A study on the New York law found roughly half of all claims taken to arbitration go to either side which, over time, helps insurers and doctor groups find the true price. Most importantly, arbitration gives struggling hospitals the fighting chance they need to stay alive.

Doctors like myself are raising our voices in communities around the country to make this same argument. I just hope it’s not too late.