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Surprise Medical Billing in Pennsylvania: What’s Being Done to Fix the Problem?

Almost one third of privately insured Americans have received a “surprise” medical bill — in which they receive a bill for a medical service they believed was covered by insurance — within the past two years.

That’s according to a survey released by the Consumer Reports National Research Center. This occurs when, for example, a patient goes to the hospital for surgery, and though the hospital and surgeon are in-network, unbeknownst to the patient, the radiologist, anesthesiologist, and/or other specialists are not.
This is not good news for patients who receive a surprise bill in their mailbox or for the physicians who want to provide the best care possible and maintain a good physician-patient relationship.

A public hearing, held in Harrisburg on Oct. 1, 2015, and led by Pennsylvania Insurance Commissioner Teresa Miller, addressed the growing concerns raised by patients and providers regarding the surprise medical bill. These bills can represent a significant financial burden to patients. One consumer group that testified at the hearing said that, in some extreme cases, they heard of bills being $6,000, $10,000, and even $35,000.

“Physicians are the last ones who would ever want to see harm come to a patient in any way, medically or financially,” said Brad Klein, MD, MBA, a Willow Grove neurologist, who testified at the hearing on behalf of the Pennsylvania Medical Society (PAMED).

Dr. Klein has firsthand experience with being an out-of-network provider. It’s not uncommon for him to accept an emergency call at 3 a.m. to help a patient in a time of need. Out-of-network billing is generally the result of a last resort or a situation outside of a physician’s control.

“We should not put the burden on the patient to decide if they will accept a provider’s care at a time when they are suffering from mental or physical ailments and truly may not have a choice as that provider is the only one available in that community to assist that patient at that time,” he said.

Dr. Klein highlighted several issues that affect Pennsylvania physicians, including:

  • Narrow networks — Dr. Klein noted that, in this era of narrow networks, some solo practitioners are excluded from network participation. Narrow networks also may drive more patients to use out-of-network services.
  • Health insurer consolidation leading to the exercise of market power by insurers in the purchasing of physician services — This is what is known as “monopsony,” the ability to reduce and maintain input prices below competitive levels. It can reduce the quality and quantity of health care below competitive levels and, in turn, harm consumers.

Physicians practicing in Pennsylvania are left with some hard choices, according to Dr. Klein. Should they leave the state to practice elsewhere, change careers, retire early, or seek employment by a larger system and hope for higher rates? PAMED is committed to helping physicians stay in Pennsylvania.

The hearing revealed the desire for collaboration amongst the stakeholders involved. Other groups at the hearing included the Hospital and Healthsystem Association of Pennsylvania (HAP) and consumer advocacy groups like the Consumer’s Union, the policy division of Consumer Reports.

Balance billing is a complex problem affecting providers, patients, and insurers. The solution will require cooperation and coordination.

“PAMED stands ready to work with the Insurance Department and other stakeholders to find a solution that protects consumers and treats providers and insurers fairly,” said Dr. Klein.

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