Opinion: For surprise medical billing, some proposals in Congress would have negative affect

By Delegate Luke Torian
(D-52, Prince William County)

In addition to our efforts in the General Assembly, some issues must be solved by the Congress and surprise medical billing is one of those issues. When members of Congress return to Washington in a few days, I believe that they should take immediate action to work on common-sense legislation that will resolve the problem of surprise medical billing.

Anyone who has been impacted by a surprise medical bill—and that’s roughly 57% percent of all Americans, according to a University of Chicago, study understands the heavy financial toll that was endured. Individuals who have received medical treatment weeks or months earlier should not be confronted with surprise medical bills which require payment for costs they assumed would be covered by their insurance company.

This problem may increase as more insurance companies reduce their provider networks.

Congress must take immediate action that does not have a negative impact on patients.

Some of the current proposals in Congress would have a negative impact.

• • There is discussion in both the U.S. Senate and House to enact legislation that would resolve out-of-network payment disputes by instituting a benchmarking solution, which would lead to government rate-setting.
  • While on the surface, this might seem to solve the problem of surprise billing by separating patients from the dispute process, benchmarking would actually create an entirely new set of problems that impact far more patients in Virginia and throughout the nation.

A benchmarking approach would set arbitrarily low rates for physicians performing out-of-network care as it would be based on insurers discounted in-network averages. Moreover, benchmarking would fail to account for the drastic differences in cost and complexity of providing clinical care in different geographical locations and among different types of health care facilities.

• • Benchmarking would give large insurance companies the power to determine the type of treatment patients can access and which physicians patients can see.
  • This system would also remove any incentive for insurance companies to negotiate fairly with providers—both on out-of-network payments and on contracts that bring more doctors into their networks.
  • Benchmarking creates a one-size-fits-all, take-it-or-leave-it system that would slash rates to physicians and transfer significant losses onto our nation’s hospitals and emergency rooms. For the facilities serving either very rural or very urban areas, the results could be catastrophic. California has tried the benchmarking approach, and it led to provider consolidation, an outcome that was devastating to rural hospitals.

These facilities, many of which are struggling as it is, serve as America’s safety net of hospitals—providing medical care for a disproportionately larger share of uninsured, underinsured, Medicare, or Medicaid patients. Jeopardizing their ability to provide care threatens access and affordability for some of our most vulnerable citizens.

I encourage Congress to reject benchmarking and instead utilize Independent Dispute Resolution (IDR), a process outlined in other legislative proposals that would provide a far more patient-friendly, equitable approach to ending surprise billing.

• • IDR would establish a fair, transparent negotiation process for insurers and providers to settle out-of-network billing disputes.
  • The IDR process would involve a third-party, independent mediator who guides those involved in reaching a decision amenable to both parties.
  • In the meantime, interim payments would provide hospitals and emergency rooms—particularly the ones serving our most at-risk patients—added stability to ensure continued access to care.
  • IDR has worked well in New York, where it was implemented in 2015, and it will work for America. For the good of my constituents and citizens in the Commonwealth, I urge Virginia’s senators and representatives to support legislation that includes this balanced approach to ending surprise billing.