Protect patients from surprise billing. Don’t put them in crossfire between insurers, physicians.

Tuyen T. Tran
Tuyen T. Tran

In a recent opinion editorial regarding surprise medical billing, the author is correct in stating that too many Kentucky patients are impacted by surprise medical billing. This is a situation when patients unknowingly or without a choice (emergency care) receive care from an out-of-network physician or other provider. Both physician and insurer agree that patients should not be caught in the crossfire in disputes between the health insurance company and physician. Other than their in-network cost-sharing obligation, patients should be protected from other costs. Similarly, a physician often does not know which networks the patient has joined; but, legally and ethically, the physician is compelled to provide services regardless of the patient’s coverage. And that’s about where our agreement on the issue ends.

The author’s assertion that the only way to fix surprise billing is with a government-mandated benchmark for physician reimbursements is wrong. By setting arbitrarily low rates for physicians, hospitals and Emergency Departments will incur tremendous financial losses which will unfortunately jeopardize healthcare access further.

The author also mentions that doctors intentionally stay out of insurance networks so they can charge exorbitant fees. This is not true. California recently passed a benchmarking “solution.”

Now, insurers are terminating long-standing contracts with physicians, undermining access to in-network care. Most health insurance markets are highly concentrated. This disproportionate leverage which the insurance industry enjoys detracts from the process of good faith negotiation with physicians. And financially, why would insurance companies seek good faith negotiation with physicians if the benchmark reimbursement is in their favor?

A major factor contributing to the surprise medical billing is an overly narrow provider network. To adequately serve patients, a network should include a proper ratio of hospital-based physicians as well as on-call specialists. Insurance companies often deny contracts to physicians without obvious cause or explanation. Financially, plans benefit when payment rates are lower, patients have higher co-payments and deductibles, and when patients are unable to obtain care from an in-network physician. The AMA has advocated stronger oversight and enforcement from the state insurance commissioners and federal government to rectify this.

Transparent regulation between providers and insurers is the true solution to surprise billing. Keep patients out of the problem. They should not be penalized. The issue is between physicians and insurers. Several states have implemented independent dispute resolution (IDR) processes that allow for fair negotiations and protect the patient. It’s time to make this a nationwide practice.

Tuyen T. Tran, MD is board chairman of the Lexington Medical Society.