How to End Surprise Billing Without Threatening Access to Care for Seniors, Rural Patients

For seniors and others living on fixed incomes, keeping up with the rising costs of health care

and prescription drugs is a difficult task.  What is making life even tougher for them is receiving an unexpected astronomically high bill weeks after undergoing medical treatment. It could be from a routine surgery or an emergency room visit at an in-network hospital, and later unknowingly receiving treatment by an out-of-network physician that is not covered by insurance.  

It is well past time for Congress to address this troubling issue at the national level since it impacts so many patients across the country.  However, as our members of Congress work to implement the best solution for this growing problem, they must be sure that the legislation does not have any negative, unintended consequences for patients, especially those living in rural areas where access to quality health care is already limited.

The Problem with Benchmarking

A particularly risky proposal, called benchmarking, that is being considered in Congress has the American Senior Alliance concerned.  Benchmarking would permit the federal government to set out-of-network payment rates for physicians by using insurance companies highly discounted in-network averages as a guide.

By setting artificially lower rates for physicians, benchmarking would cause many challenges.  First, it would transfer significant financial losses onto local hospitals, emergency rooms, and other health care facilities, many of which are struggling just to get by. Additionally, it would force many rural hospitals and emergency rooms to scale back their services, lay off much-needed staff, or even close down altogether.  If that is not bad enough, it will contribute to our nation’s growing doctor shortage and increase the already high rate of provider consolidation, especially in rural communities.  Lastly, it will make it much harder for seniors and rural patients to access the care they need at prices that won’t break the bank.

Often, emergency rooms serve as the primary point of care for America’s seniors and rural patients, especially in a state like Alabama. Undermining access and driving up costs at these facilities would be devastating for some of the most at-risk patients here and throughout the nation.

The Right Path Forward

Fortunately, a far more effective solution for surprise billing can be found in an approach called Independent Dispute Resolution (IDR). Under IDR, patients would be protected from surprise medical billing and only held accountable for their in-network cost sharing amounts—all without jeopardizing rural health care access, affordability, or quality.

The IDR process is simple, effective, and fair. Here is how it would work: Both providers and insurers submit their best payment offer through an online portal.  An unbiased, third-party mediator would then review these offers as well as a number of factors and independent data.  Within 30 days, the mediator would determine a final payment amount based on the true market value of the services provided.  In the interim, initial payments to providers would help ensure financial stability and security for struggling hospitals and emergency rooms serving our rural communities.

Ultimately, the Independent Dispute Resolution is the right path forward to eliminate surprise medical billing without disrupting health care for America’s seniors and rural communities. Montgomery's U.S. Representative Terri Sewell serves as Vice Chair of the powerful House Committee on Ways and Means may have this measure before her in committee.  We trust Representative Sewell and the rest of Alabama’s elected members of the U.S. House and Senate will oppose benchmarking in any form and work together to pass a solution that includes the all-important Independent Dispute Resolution approach. 

Conwell Hooper is the executive director of the American Senior Alliance, a not-for-profit organization that advocates for senior citizens.

This article originally appeared in The Montgomery Advertiser.


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