Ways to Address Surprise and Balance Billing

Since the rollout of PPACA / Obamacare, the entire healthcare industry has started rapidly consolidating; and that has resulted in double-billing from hospital owned providers, resulting in additional bills for “Facility Fees”; and fewer “In-Network” doctors, resulting in additional Out-of-Network bills and/or bills for Non-Covered services. Therefore, we need to establish new “Out-of-Network” limits for what a person can be charged by an Out-of-Network Provider.  While some States and CMS are starting to address these issues, they need to be addressed sooner, rather than later. 

These are two (2) possible scenarios to address these ‘new’ issues that have come about from PPACA / Obamacare.

  • If a Provider is working at a Network Contracted Provider, such as in a Hospital Emergency Room or Surgical Center, that is a “Certified and Licensed” Medicare Provider, then the limit of the Out-of-Network bill could be 3 times what Medicare pays for all the provided services. 
  • If a person’s health plan does not cover a service at a Contracted Network Provider, due to the insurance company deciding it is a “non-covered” benefit, including ER visits deemed non-emergency after-the-fact; then, the Insurance company “must extended the network discount price to the insured individual” even though it will not count towards the out-of-pocket maximum of the health plan.

The result is that many unexpected balance bills that people get today would at least be set to be no more than what the insurance company would pay or 3 times the Medicare rate, instead of unlimited and sometimes outrageous bill rates.  People are paying for the health insurance plan to administer their benefits; therefore they should be entitled to the health insurance plans discounts, even on non-covered benefits.  HHS/CMS should be able to require this of Medicare Certified and Licensed Providers.