Large and unexpected balance billing of patients by out-of-network providers is a growing concern for patients as well as for employer plan sponsors. These “surprise” medical bills frequently arise from emergency care or treatment provided by an out-of-network hospital or facility or an out-of-network provider to an in-network facility. In such cases, after the patient’s health plan pays benefits under the terms of the plan, the out-of-network provider submits a bill to the individual for the difference between the amount paid by the plan and the billed charges.
Many states have passed laws to protect consumers from these “surprise” bills. Federal legislation expected to be taken up next year in Congress to address the practice could have far-reaching consequences for the healthcare system. The legislation will likely apply broadly to group health plans – whether insured or self-funded – as well as individual policies.
If properly crafted, legislation could help solve this problem in a way that protects both patients and payers. If not, new requirements could increase healthcare costs and reduce access to quality care in part by making it difficult to design health plans with networks attractive to providers and patients. To that end, the nine groups—including the American Benefits Council and the ERISA Industry Committee -- called on Congress to craft legislation that embraces four principles:
Mercer is working with Congress and employer groups to help craft workable legislation that protects patients from unexpected costs while improving healthcare affordability and access.