AAFP Joins Call to Protect Patients From Surprise Bills

Medical Groups Lobby Congress to Improve Coverage Transparency

February 19, 2019 03:46 pm News Staff

There are two kinds of people: those who hate surprises, and those who hate surprise medical bills.

[woman reading bill in mail]

Recognizing that the latter group includes not only U.S. primary care patients but also their physicians, the AAFP this month signed on to a letter calling on lawmakers to protect Americans from unexpected medical costs.

"Patients, physicians, and policymakers are deeply concerned about the impact that unanticipated medical bills are having on patient out-of-pocket costs and the patient-physician relationship," said the Feb. 7 letter.(5 page PDF) It was sent to Reps. Richard Neal (D-Mass.) and Kevin Brady (R-Texas) -- the chair and ranking member, respectively, of the House Ways and Means Committee -- and signed by more than 100 state and national medical organizations.

For patients, surprise bills are the common thread of widespread horror stories(www.npr.org) and, in some cases, have led to court intervention.(www.nytimes.com)

The associated dread is quantifiable. According to a 2018 Kaiser Foundation poll,(www.kff.org) 39 percent of insured adults ages 18-64 said they'd been billed unexpectedly in the past year after receiving "care from a doctor, hospital or lab that they thought was covered and their health plan either didn't cover the bill at all or covered less than they expected." The same poll said 67 percent of Americans worried about surprise medical bills.

Physicians hear these worries, the letter pointed out, but "are limited in their ability to help patients avoid these unanticipated costs," in part because they may not know who will treat their patients in an emergency. They're also unlikely to be briefed on their fellow physicians' contract status with all the insurers in their communities.

Attempts to limit such billing practices have gathered momentum in recent years. Federal legislation on the matter during the current session of Congress would carry forward bills introduced in 2017(www.congress.gov) and 2018.(www.congress.gov)

Pressure in Washington is also coming from insurers. This past December, nine groups, including the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the National Business Group on Health, and Consumers Union, lobbied Congress(www.modernhealthcare.com) to prohibit certain out-of-network billing practices.

The AAFP and its co-signatories urged consideration of several policies in their letter, including:

  • Insurer accountability: The letter said that narrow networks contribute to surprise billing. "Strong oversight and enforcement of network adequacy is needed from both federal and state governments."
  • Limits on patient responsibility: Patients should be responsible only for in-network cost-sharing rates when experiencing unanticipated medical bills.
  • Transparency for scheduled health care: "When scheduling services for patients, providers should be transparent about their own anticipated charges, and insurers should be transparent about the amount of those charges they will cover."
  • Benchmark payments: "In general, caps on payment for physicians treating out-of-network patients should be avoided," the letter said. "If pursued, guidelines or limits on what out-of-network providers are paid should reflect actual charge data for the same service in the same geographic area from a statistically significant and wholly independent database." These should not be based on "increasingly inadequate" Medicare rates or on in-network rates, which would hinder good-faith contract negotiation from insurers.
  • Keeping patients from being middlemen: Payment rate negotiations should be between insurers and those who provide medical care, the letter said. To ensure that patients aren't stuck doing that work, "physicians should be provided with direct payment/assignment of benefits from the insurer."