An unfortunate but common feature of the U.S. health care system is surprise billing — an unexpected charge not covered by insurance even though the patient received care at a facility or from a doctor they believed to be within their insurance network. The coronavirus pandemic is creating more situations in which patients might receive care from an out-of-network provider, and state and federal policies, including some specifically aimed at COVID-19 patients, don’t adequately protect patients from receiving surprise bills. The nation should expand surprise billing protections to include all patients, now and after the coronavirus pandemic ends.
Surprise billing is a problem for both consumers’ finances and their health. The average surprise bill is for $1,500, more money than many Americans have on hand. Fear of big medical bills can deter people from seeking care, harming their health and potentially the health of those around them. For example, a recent poll found that one in seven Americans would avoid seeking medical care even if they experienced classic symptoms of COVID-19 because they feared how much treatment would cost.
Fears of surprise bills aren’t unreasonable. In 2017, one in six Americans reported having received a surprise medical bill. Surprise bills are especially common for emergency room visits, with multiple studies finding that emergency care doctors have some of the highest rates of surprise billing. That’s because in many cases emergency room physicians are employed by independent staffing firms, not the hospital. Lab tests ordered during a hospital stay are also a common source of surprise bills, as are anesthesiology services.
Patients don’t have the ability to avoid most of these surprise bills. In an emergency or when sick enough to be hospitalized, patients are not in a position to query every provider about their billing practice. Nor should they have to. Surprise bills are common at in-network hospitals, meaning patients have already made an attempt to seek care that will be covered by their insurance.
COVID-19 has the potential to make surprise billing even more common. Emergency room physicians and laboratories, some of the most common sources of surprise bills, have a large role to play in the COVID-19 response (though at least one firm has said they will suspend surprise bills for COVID-19 patients). In addition, as hospitals in COVID-19 hotspots increase staffing, they may do so by turning to physician staffing firms or other physicians who don’t normally work there and thus aren’t in-network.
Solving this problem requires policy action.
Multiple states have adopted surprise billing protections for patients in recent years and also on an emergency basis in response to COVID-19, though those measures have failed to fully curb the problem. In fact, some of the states with the strongest protections, such as California, also continued to have some of the highest rates of surprise billing. (See figure below from Health Care Cost Institute) Some of the problem stems from the fact that state-level protections apply only to state-regulated plans, such as those sold through the Affordable Care Act exchanges and some employer-sponsored plans. State-level protections do not govern self-funded employer-sponsored plans. More than half of workers with employer-provided insurance are in self-funded plans, which are regulated by federal law.