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My turn, Mary Younts: Lawmakers must tackle billing the right way

By Mary Younts

For most Americans, health problems are hard enough.

Surgery, injuries and other medical emergencies already come with a heavy mental toll. The last thing a patient needs is the trauma of a major, unexpected medical bill as they are working their way through the recovery process.

Unfortunately, surprise medical bills are becoming all too common. They happen when insurers refuse to pay for out-of-network care, even though the patient had no way of knowing the doctor providing their treatment was not part of their insurance network. Surprise bills are most common after trips to the emergency room, when patients in need of immediate care do not have the luxury of researching the location of the nearest in-network hospital.

Even though the patient had no control over where they received care, insurers refuse to pay for it, instead passing the portion of the bill they fail to reimburse directly to the patient.

As a home health nurse, I see the anguish caused by surprise medical bills all too often. Patients dutifully pay their insurance premiums every month only to see those premiums rise every year as well as deductibles and out-of-pocket expenses. They expect their insurance to be there when they need it. But often times, that just isn’t the case.

I was pleased to see that President Donald Trump and members from both parties in Congress called for legislation that would end surprise medical billing. However, as the legislative process has played out in Washington, I’m disturbed that the proposal favored by the insurance industry — the very people responsible for surprise medical bills — has gained momentum with some lawmakers on both sides of the aisle. Congress should take a beat and consider the painful consequences of the insurance industry’s favored legislation and find a different path forward.

Insurance companies are pushing for an approach known as rate setting.

Rate setting allows insurers to benchmark out-of-network reimbursements to their own in-network rate. That way, the thinking goes, providers who provide out-of-network care would receive the same payment as in-network providers, eliminating any need for a surprise bill. As you might guess, giving insurers the ability to set their own reimbursement rates would lead to disastrous consequences.

Basing the out-of-network rate on in-network payments gives insurance companies enormous incentive to slash their in-network rates as much as possible.

Most immediately, this leads to smaller insurance networks for patients, who will see out-of-pocket costs rise. Drastic rate cuts also make it harder for doctors and hospitals to stay in business. This is particularly problematic in rural and underserved areas, including many parts of the Triad, where many hospitals are already facing serious financial challenges.

Losing those emergency rooms would force local patients to travel farther during a medical emergency, which could literally be the difference between life and death. California tried the rate setting approach and it has already led insurers to cancel contracts with providers to drive rates down.

Instead of the failed California model, Congress should look instead to a proven solution that is already working at the state level.

Several states, including Texas and New York, have adopted an independent dispute resolution system that removes patients from the middle of billing disputes. Instead, it allows doctors to resolve out-of-network disputes through an arbitration process, ensuring that neither party gains an upper hand over the other. This a system is designed to be fair, and other states have seen a fairly even split in rulings between insurers and providers.

Every day, I care for patients who are living with serious medical challenges. They deserve to know that their insurance will cover them in an emergency.

But by refusing to pay for that care, insurance companies are responsible for surprise medical bills.

Congress shouldn’t try to solve this problem by giving even more power to the guilty party. Lawmakers are right to tackle surprise billing, but for the sake of our patients, they have to do it the right way.

Mary Younts works as a home health nurse in Rowan and Cabarrus counties.

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