According to HealthPayerIntelligence (September 4, 2018) 86% of Consumers Blame Insurers for Surprise Healthcare Bills
In the PPO/HMO model a surprise bill is one that is either declined because the services aren't covered by the plan or the provider isn't participating in the particular network the member has. These bills can be small or very large but in any event they are very painful to the member because they come unexpectedly. A study conducted by the NYSDFS found the average surprise bill related to an ER visit left the member owing just shy of $3,800. Some states have regulations protecting the patient for these types of bills. New York passed legislation last year after studying thousands of complaints submitted by residents who received surprise bills. The bill protects patients who receive such bills for emergency and non-emergency care. According to the Kaiser Family Foundation patients who receive a surprise bill for emergency services, patients insured by state-regulated health plans (e.g., not including self-funded employer plans) are held harmless for costs beyond the in-network cost sharing amounts that would otherwise apply. Patients who receive surprise out-of-network bills for non-emergency care can submit a form authorizing the provider to bill the insurer directly, and then are held harmless to pay no more than the otherwise applicable in-network cost sharing. In both situations, out-of-network providers are prohibited from balance billing the patient; although providers who dispute the reasonableness of health plan reimbursement may appeal to a state-run arbitration process to determine a binding payment amount. The New York law applies only to state-regulated health plans. However, patients who are uninsured or covered by self-insured group health plans may also apply to the state-run arbitration process to limit balance billing by providers under certain circumstances. Federal and State Policymakers have expressed concern that surprise medical bills can pose significant financial burdens and are beyond the control of patients to prevent since, by definition, they cannot choose the treating provider. Various policy proposals have been advanced, and some implemented, to address the problem. These include hold harmless provisions that protect consumers from the added cost of surprise medical bills, including limits or prohibitions on balance billing. Others include disclosure requirements that require health plans and/or providers to notify patients in advance that surprise balance billing may occur, potentially giving them an opportunity to choose other providers.