Surprise health billing illustrates how illogical the American health system is

Surprise health billing illustrates how illogical the American health system is
© iStock

This month, Congress and the Trump administration are considering what to do about the problem of surprise health-care bills. They would be wise to use Connecticut as an example, where one of the most comprehensive sets of reforms was instituted two years ago.

Surprise bills, or “balanced bills," are the difference between what the out-of-network physician charges and what the insurance company will pay.


According to a survey conducted last year by the National Opinion Research Center at the University of Chicago, 57 percent of American adults have been surprised by a new medical bill that they thought was covered by insurance.

In some cases, surprise bills illustrate just how opaque and illogical the American health system has become. Imagine if you ordered soup in a diner for $8 and then found out you were being charged $30 for the spoon.  

I have been concerned about the confusion, angst and in some cases financial devastation patients experience when they suddenly receive large and unexpected medical bills.

This often happens when there are unanticipated charges from out-of-network clinicians, even though the patient had gone to an in-network hospital or even seen an in-network primary care physician.

Connecticut’s experience is a good place to begin. Researchers at the Robert Wood Johnson Foundation and Georgetown University report that insurance regulators in a number of states see progress in limiting balance billing using reforms like we have implemented in Connecticut.

In addition, Connecticut is one of only nine state with laws that meet the standards that the Commonwealth Fund, a leading think tank on health care, calls “comprehensive” protection. Sixteen additional states offer consumers some protection against balance billing but leave out key pieces. What Connecticut is doing is working.

At my health system, we also provide our patients with cost estimates before services are rendered whenever circumstances are feasible. Trust is not simply about clinical care; it is the entire patient experience, including the bills a patient gets once they are back home.

Although not perfect, the results of the legislation in Connecticut indicate that there are workable solutions and that the key players — insurers, doctors, hospitals and government — can together resolve a series of problems that have unfairly ensnared millions of Americans.

Here are a few basic ideas in Connecticut’s surprise billing law, which applies only to non-ERISA insurance plans:

1. A “hold harmless” protection: insurers cannot hold any Connecticut patient financially liable for any portion of a medical bill beyond the usual co-pays and deductibles of their in-network coverage.

2. A prohibition on balance billing: physicians or other providers are prohibited from sending a balance bill to the patient for any amount beyond in-network cost sharing. A “balance bill” is when a provider bills a patient for the difference between the provider’s charge and the insurance company’s allowed amount for the service(s).

3. Emergency room care: Connecticut consumers are protected for emergency services provided by out-of-network providers at both in-network and out-of-network facilities.

4. Non-Emergency Care: Connecticut consumers are also protected from the costs of non-emergency care provided at an in-network facility.

Unfortunately, state laws are only a beginning. Washington must decide what to do about the tens of millions of Americans who are covered by self-insured employer plans that fall under the jurisdiction of the Employee Retirement Income Security Act of 1974 (ERISA) — an area where state laws do not apply.

There are other issues as well, including whether to provide a formula that insurers must follow in determining how much to pay an out-of-network provider or whether to settle disputes through an arbitration process. Many such issues could be addressed by some of the plethora of proposals now before the Senate and the House.

Whatever solutions Washington finally agrees upon, agreement should be reached between payers, providers and the government without asking anything more from consumers. Too often, our health-care system supports well-being in clinical care, and then unravels it with administrative and financial burden.

Patients should be able to see providers in the community where they live and be protected against overwhelming financial consequences, especially in urgent medical circumstances. In Connecticut, we are on the road to this patient-first environment.

The trap of surprise billing has been stressful enough for patients. It is time to leave patients with less to worry about.

Kathleen Silard RN is the the president and CEO of Stamford Health.