Narrowing health networks and a lack of transparency represent “the root cause” of surprise billing, the president of the Pennsylvania Medical Society told state Insurance Commissioner Teresa Miller in a letter sent earlier this week.
“At the most basic level, patients need to understand their financial responsibility for seeing non-participating providers,” said Scott E. Shapiro, a cardiovascular disease and internal medicine specialist from Montgomery County.
Surprise billing — when patients face high medical bills after unknowingly being treated by an out-of-network provider — has drawn special attention from Ms. Miller, who convened a special hearing on the issue last fall.
In January, her office proposed a number of steps to prevent situations where, for example, a patient is operated on by an in-network surgeon only to learn later that their out-of-network anesthesiologist would be charging full price for services the patient thought were covered by insurance.
Public comments on the proposal closed Monday, and the insurance department has said it wants to work with legislators, consumers and stakeholders to draft legislation addressing this issue.
One key provision of the department’s plan would hold patients responsible only for the expected in-network co-payment, while the insurer and provider would have to sort out a payment amount. Unresolved cases would be sent to arbitration.
Dr. Shapiro’s letter highlights some of the nationwide forces behind the emergency of surprise billing.
To control costs, insurers are designing narrower networks that restrict which providers and health systems they can see on an in-network basis. That’s become more common in Pittsburgh, too, since UPMC, the region’s major provider, and Highmark, the region’s dominant insurer, have parted ways.
Dr. Shapiro called for requiring insurers to get state regulatory approval before health insurance plans go to market, as well as when significant changes are made to existing insurance plans.
“A network that does not provide adequate access to in-network care at contracted hospitals should simply not be sold to consumers,” he wrote.
He also argued that insurers should provide patients — at the time of enrollment — the expected range of what their out-of-pocket costs may be if they receive care from an out-of-network provider. He added, “It is also important that insurers base their payments to non-participating providers on usual, customary and reasonable charges” from an independent source.
Asked for comment on the medical society letter, Highmark spokesman Aaron Billger on Tuesday said the insurer believes patients “should be protected from enormous charges from out-of-network providers, especially in emergency situations.”
Gina Pferdehirt, spokeswoman for UPMC Health Plan, said UPMC, too, wants to find ways to eliminate surprise billing.
“We at UPMC Health Plan believe that providing consumers with the information they need to make wise coverage decisions is essential, including clear and understandable information about the providers in our networks.”
Steve Twedt: firstname.lastname@example.org or 412-263-1963.