Dear Mr. President,

As you mentioned during your health care round table last week, surprise medical bills are a serious problem. Fortunately, if you are serious about finding a solution to this problem, we know what needs to be done.

Surprise medical bills—medical bills a patient unexpectedly receives from an out-of-network provider—are a growing health care concern for many individuals and families. Surprise medical bills can happen to anyone, no matter what kind of health insurance they have. When patients use providers that are not in their health plan’s network, they are directly billed by these providers the difference between what their health plan agrees to pay and what the provider charges. Such a practice is known as balance billing and can add up to hundreds or thousands of dollars, leaving patients with little recourse and potentially devastating medical debt. Surprise medical bills are what people fear most, more than they worry about prescription drug costs, premiums and other cost sharing requirements, or other costs of goods and services (such as rent, food, utilities, and transportation).

As you vowed to “stop all of it,” we, a consumer health advocacy organization, encourage you to adopt a comprehensive approach that holds patients harmless from these unfair balance-billing practices. To effectively hold patients harmless you must move beyond price transparency and explicitly prohibit billing patients in situations where consumers cannot reasonably be expected to know they are receiving out-of-network care.

Price transparency is not enough to hold patients harmless from surprise medical bills. You stated that patients should be informed of “exactly what the cost is” before they receive care. Though transparencyis crucial in helping patients make the health care decisions that are right for them, price transparency alone does not improve health care quality and affordability for patients. In fact, only 7 percent of patients’ out-of-pocket health care spending is estimated to be on “shoppable” services, suggesting that the purchasing power of consumers has limited ability to drive affordability and quality of care.

Unlike shopping for other goods and services (such as getting a car repaired or buying groceries), in many cases patients have no opportunity to shop for their health care. As you heard during the roundtable discussion, many of these unexpected and outrageous medical bills result from emergency care or when an individual unknowingly receives treatment by an out-of-network physician at an in-network facility. A carefully planned visit to an in-network facility or an emergency visit to a local hospital could result in services delivered by out-of-network physicians; for instance, an anesthesiologist in the emergency room assisting a surgery; a pathologist examining a biopsy; or taking an ambulance (ground or air) trip to a hospital.

Holding patients harmless in these scenarios requires a complete ban of surprise medical bills that explicitly prohibits providers from balance billing patients in all situations where they cannot reasonably be expected to ensure they are receiving in-network care. Those situations include, but are not limited to:

  • Emergency care, including ambulance transportation. In many cases, emergency physicians and the hospitals where they work do not contract with the same insurers. As a result, despite going to an in-network hospital for emergency care, a patient might be treated by an out-of-network physician. Nationwide one in five in-patient emergency admissions leads to a surprise medical bill, and more than half of these cases involved ambulance transportation.
  • Unexpectedly receiving care from out-of-network providers at an in-network facility. Similar to emergency physicians, providers such as anesthesiologists, pathologists, radiologists, neonatologists, or assistant surgeons might be out-of-network even though they work at an in-network facility. For example, a patient could arrange for a hip replacement with an in-network surgeon at an in-network facility, but the assistant surgeon helping with the surgery and the radiologist performing the MRI could be out-of-network. In these situations, patients have no means to check if any out-of-network providers are part of their care team.
  • Inadvertently receiving care from out-of-network providers due to inaccurate provider directories. A patient could do everything right to make sure they receive care from providers that have contracted with their health plan, but if they unknowingly rely on an inaccurate provider directory, they could end up inadvertently receiving care from an out-of-network provider.

As hard working individuals and families struggle to pay for health care services, it is very clear that what people want is for policymakers to find a way to make their health care costs more affordable. If you truly have the will, we know there’s a way.  

A ban on surprise balance billing is just one approach to addressing surprise medical bills. Stay tuned for our upcoming policy brief that includes policy recommendations that provide a comprehensive approach to tackling surprise medical bills.

Yours sincerely,

The millions of hard working individuals and families in America who have experienced a surprise medical bill.