TAKING THE STING OUT OF SURPRISE BILLING

BROAD SPECTRUM Taking the Sting Out of Surprise Billing

Patients have long suffered financial strain from exorbitant, surprise medical bills stemming from out-of-network care. Collaborative work through the USC Schaeffer Center for Health Policy & Economics has informed numerous pieces of legislation at the state and federal levels to protect consumers from this practice, also known as balance billing.

The most sweeping of these is the federal No Surprises Act, which went into effect on January 1, 2022. In addition to making it illegal to bill patients for more than in-network cost sharing for certain services, the legislation establishes an arbitration process to resolve disputes between providers and insurers.

In a piece for Medpage Today, Erin Trish and colleagues note that most doctors don’t want to send balance bills to unsuspecting patients and that physicians not currently profiting from surprise billing “could see pay increases because of the law’s new out-of-network price support.” The Schaeffer Center’s work in this arena is conducted through its partnership with Brookings Institution in the USC-Brookings Schaeffer Initiative for Health Policy.

The researchers expect the No Surprises Act to save money overall because it uses median in-network prices to guide payment decisions—a strategy outlined by the Schaeffer Initiative in early research. “The law is a big win for patients, employers and consumers,” adds Trish, Schaeffer Center co-director and an assistant professor in pharmaceutical and health economics at the USC School of Pharmacy.

Bringing Expenses Down to Earth When it comes to emergency services, air ambulances account for some of the highest surprise bills. The lack of competition is a factor as, by 2017, just two private equity firms had gained control of nearly two-thirds of the Medicare market for air-ambulance transport.

Analyzing commercial insurance claims data for 2014–2017, Trish and colleagues found that emergency medical air transports from providers owned by private equity or publicly traded companies were paid an average of $32,051—5.6 times what Medicare would have paid. This is particularly concerning, they say, given that 89% of transports provided by private equity or publicly traded companies during this timeframe were out of network.

Fortunately, air-ambulance providers are among those covered by the No Surprises Act, which will protect patients from these surprise bills going forward and should lower prices. However, more can still be done to protect patients and improve the market, the researchers add.

Erin Trish