Congress must end surprise billing — in a fair and reasonable way | Guest editorial

The state Legislature recently passed an act that eliminates protects patients from surprise medical billing.

  • Monday, January 6, 2020 9:28am
  • Opinion

By Dr. Sean Kincaid

Special to the Reporter

One of the foremost goals of any physician anesthesiologist is to ensure the most positive, painless patient experience possible. However, there is only so much we can do to protect patients from the pain of getting hit with high, unexpected medical bills demanding payment for the cost of care they assumed would be covered by insurance.

Fortunately, the Washington Legislature passed the Balance Billing Protection Act, based on input and compromise by providers, insurers, the insurance commissioner and other stakeholders. It eliminates this practice and protects patients from surprise medical billing. However, too many patients nationwide remain vulnerable — as do Washington patients if they are treated outside our state’s borders. That is why it is vital that Congress pass a federal solution to end surprise medical billing nationally.

As they continue to hammer out such a solution, lawmakers in Washington, D.C. must be careful to leverage a fair, workable approach for all parties involved. That means avoiding a particularly harmful proposal known as benchmarking, which could undermine access and affordability for patients while failing to address one of the key contributors to this problem: inadequate provider networks.

Whatever legislative solution Congress passes must not only hold patients harmless for unexpected medical bills, but also ensure adequate network standards so these insurance gaps never happen in the first place. A solution that has been proposed in Congress, called Independent Dispute Resolution (IDR), would achieve both of these goals.

As the basis for Washington’s state law, the IDR process would allow physicians and insurance companies to negotiate out-of-network billing disputes among themselves, removing patients from the process. Each “side” would submit their payment offers through a simple, online platform and an ultimate decision as to the final amount would be determined by a third-party, independent mediator who would ensure payments are fair, accurate, and based on the true cost of providing clinical care.

What’s more, an IDR-based approach would incentivize insurers to engage in fair contract negotiations with physicians, helping to strengthen network adequacy and grow, rather than continue to shrink, provider networks. This is also the approach that has been working well in New York since 2015, when state legislators passed a strong, IDR-focused solution there. Since then, in-network participation is up, out-of-network billing is down and emergency care costs have also dropped.

This is a vastly better solution than another proposal that Congress is considering, known as benchmarking. Under a benchmarking approach, the government would set inordinately low out-of-network rates for physicians, which would shift enormous losses onto hospitals and emergency rooms. For many of our state’s at-risk health care facilities serving rural, hard-to-reach, or otherwise under-served communities, a benchmarking solution could jeopardize patient access to care while driving costs up.

Sen. Patty Murray, who has cosponsored a benchmarking-based proposal, should reconsider this flawed approach and work to replace it with the far more effective and equitable IDR process. Ultimately, this is best solution to protect all patients from surprise medical billing while strengthening network adequacy and preserving vital access to rural health care.

Dr. Sean Kincaid is the president of medical staff at EvergreenHealth in Kirkland. He has served on the board of the Washington State Society of Anesthesiology, in positions including treasurer, secretary, vice president, and president, as well as in the role of delegate to the American Society of Anesthesiologists.

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