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The Surprising Truth Behind Surprise Medical Bills

The Surprising Truth Behind Surprise Medical Bills

If you have ever received an unexpected medical bill, it may be time to stop blaming your physician and look at your insurance.  Surprise medical bills are becoming an increasing problem in this country.  They occur whenever a patient receives a bill for the balance of medical services despite the payment of the deductible and copayments. According to recent data, 1 in 5 insured adults have received a surprise medical bill.  What most people do not realize is that surprise billing can be a surprise to your physician as well.

Receiving care from a physician out of network is the typical cause of surprise billing.  Due to the increased complexity and narrowing networks within insurance plans, both the physician and patient may be unaware that care is being provided by an out of network physician in an in network medical facility.  Despite the false narratives, it is the health insurance industry that is causing surprise billing by creating narrow networks and dropping physicians who previously negotiated to be in-network.  Based on my 14 years of experience as a physician, it’s time to hold the industry accountable.

At the beginning of this year, patients were set to receive relief under the No Surprises Act which bans surprise billing in private insurance in different circumstances. Under the new legislation, patients with insurance will have greater protection against surprise bills when they are in an in-network hospital for a procedure or anytime a patient receives emergency care.  While physicians were heavily involved in crafting language for the No Surprises Medical Bill Act, the interim final rule contains language that favors insurance companies in disputes which could ultimately impact patient access. The American Hospital Association, American Medical Association  and other medical specialties filed suit.  In response, some proponents have painted physicians as greedy.  Negotiating in good faith for fair compensation is not greed.

Each year, physicians negotiate with insurance companies to receive an agreed upon payment for providing service to their members.  The negotiations are intended to provide cost reduction fees with patients.  A 2020 survey from the American Society of Anesthesiologists concluded that anesthesiologists were being forced from in network to out of network status as a result of aggressive tactics by insurance companies terminating their contracts with little or no notice. Forcing physicians out of the network harms both physicians and patients.  In fact, the only one who benefits are insurers who can increase their profit.  These types of aggressive practices suggest that favoring insurance companies in disputes is a bad idea.

Many insurance companies such as United Health Group, Aetna, & Blue Cross Blue Shield have routinely dropped physicians from their plan. They subsequently offer new contracts at 60% less than their previous agreed upon fees, only to force physicians out of network. Insurance companies have also encouraged underpayment to physicians and delayed processing payments for services provided. United Healthcare lost a multi-million dollar lawsuit brought by TeamHealth, a company that operates emergency room staffing and billing companies.  TeamHealth alleged the insurance company’s shared savings plan deliberately encouraged underpayment or termination of physician contracts.  The jury found that United Healthcare deliberately engaged in unfair reimbursement for frontline emergency room physicians and encouraged underpayment of physicians in 11,000 claims.  This is not the first incident in which United Healthcare undercut payments for care including mental health care.  In 2021, United Healthcare Group and/or its affiliates was ordered to pay over $13 million in a suit brought by the U.S. Department of Labor for imposing more restrictive limitations on mental health benefits than medical benefits.

Despite the rhetoric, it is the insurance industry, not physicians who are demonstrating greed.  In fact, the annual earnings have demonstrated UnitedHealth Group and other insurance companies have attained big profits even during the COVID pandemic. In the first quarter of 2021, United Healthcare reported an earnings of $4.4 billion compared to $3.4 billion in 2020. This represented a 44% increase in profits. United Healthcare Group was not the only one to see increased profits. In 2021, United Health, CVS Health and Anthem continued to demonstrate increased earnings while front line physicians demonstrated overall employment instability and reduction in compensation. 

It’s time for the patients and the public to recognize that the villainous portrayal of physicians by big profit insurance companies as greedy is a fiction.  Presently, 152 lawmakers have called upon the Biden Administration to prevent the insurance industry from artificially creating low reimbursement rates and narrow networks.  Physicians have worked tirelessly to ensure patients are not put in the middle of unexpected medical bills.  It is time to end the false narratives and offer support to our physicians.

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