I Have to Pay What? The Current State of Surprise Medical Billing

Health insurance is a beautifully, complex thing. Costs for healthcare often varies by the insurance plan. Some plans pay for every penny, while others are more selective in what is covered. However, in the grand scheme of things, when an individual visits a health facility, they can pretty much expect most of their costs to be covered. Yearly checkup? Covered. Flu shot? Covered. Collapse at work and require an ambulance trip to the hospital? Covered, but not covered. Surprise medical bills create an unnerving sense of the unknown.

As AAF President Douglas Holtz-Eakin notes in his piece on The Daily Dish, “a surprise medical bill occurs when the patient receives a bill from a provider who is not in her insurance company’s network” [I]. A surprise medical bill may arise if a procedure is scheduled at a hospital where you are covered but the specialist is out-of-network. Your insurance will cover the costs that are from the hospital, but not the costs from the out-of-network specialist.

In one instance, a school librarian in Findlay, Ohio felt her heart racing and could not get her pulse to go down. After visiting the school nurse and no luck getting her heart rate to slow down, she was rushed across the city in an ambulance to the nearest hospital. Shortly after the incident, she received a bill for $1,206 for the 4-mile ambulance ride – more than $300 a mile [II]. She was required to pay $859 of that bill because the only emergency medical service in the city did not have a contract with the insurance plan she has through her job [II]. These instances make individuals feel as if they should have had a loved one or friend take them to the hospital, and some people just avoid care all together.

In March of this year, Virginia passed legislation to ban the “balance billing” of what insurers won’t pay for [III]. This keeps patients from worrying about the possibility of receiving a bill that is beyond their expected deductible or co-pay [III]. This bill keeps patients from being stuck with a large sum after they visit the emergency room or have an expensive procedure or surgery. This is the same approach Washington state has implemented [III]. While the approaches may differ, lawmakers are seeing an increase in the number of states that are drafting legislation to address these surprise medical bills.

With the states leading the way, we will also see Congress making steps to avoid these surprise medical bills. As Chris Holt, AAF Director of Health Care Policy, points out in his Weekly Checkup, roughly 30 states have acted to protect patients from unforeseen costs [IV]. It is worth noting that these measures are being taken by republican states, democratic states, and swing states alike. However, without federal legislation addressing this issue, many people are still unprotected, even in states with relevant legislation. Federal policymakers are continuing to work on a solution but the “growing consensus in approach at the state level” will be something to pay attention to [IV].