Jan. 1, 2022, was an important day for Americans. In one of the few outright wins for American consumers in recent memory, federal legislation forbidding “surprise medical billing” went into force.
Anyone who has had a brush with emergency room or hospital care has probably been subjected to this practice. While the hospital you find yourself in may check out as an “approved, in-network” facility according to your health insurance, the various doctors and specialists you see inside the hospital may not be, and you would not know that. And if these professionals are not in your network, they were entitled to “balance bill” you — that is, to bill you the difference between what your insurance paid to them and what they assert they are owed. Americans were often left owing thousands, even tens of thousands, of dollars in balance billing, which became a serious risk factor for bankruptcy.
Insidiously, it’s often when you are least capable of protesting that such surprise bills would occur. Emergency room physicians are almost always out-of-network doctors, but you wouldn’t be seeing an ER doctor unless you had no other choice. (I once walked out of an ER when they refused — refused! — to tell me if the ER doctor was in my network or not.) Specialists who look at your X-rays or administer anesthesia to you may not be in your network — and these may be doctors you never saw or interacted with at all; you might not know of their involvement in your care until the bills started showing up.
The U.S. Congress, to its surprising credit, legislatively fixed that problem for Americans as a 2022 New Year’s gift. You, the consumer, will no longer receive a “balance bill” from being treated at an in-network facility by an out-of-network professional. You will pay your usual copays and deductibles, but then the professional and the insurance company will have to negotiate through arbitration a price the insurance company will pay. The good news is that such arbitration may push prices more toward an acceptable medium price point, thereby slowing the rise of insurance premiums. It will also surely nudge professionals whose business models relied on predatory balance billing, such as some ER physicians, to join insurance networks.
Of course, the law is not perfect. There never has been a bill passed by Congress that did not have some problem. The primary issue with the new legislation is that while almost all forms of medical care are included, there is one glaring exception: ground ambulances. (Air ambulances are covered by the new legislation, unaccountably.) Ground ambulances may still “balance bill” you despite the new law, and the average cost for a ground ambulance ride — which you will most likely pay out of pocket through your copay/deductible plus the balance bill — amounts to about $1,200 per patient transported. In Texas where I live, 85% of ambulance rides are out-of-network; in Houston, 100% are.
And horror stories abound. Reader comments on a recent New York Times article, for instance, run the gamut: ambulance bills of up to $4,000, getting double-billed for an ambulance and an unnecessary fire truck dispatch, a gymgoer getting slapped with a bill after injuring himself and having an ambulance called as a matter of gym “policy.” And on it goes.
We live in a strange land if the first thing out of an injured person’s mouth is, “Don’t call the ambulance!” but that’s an obvious temptation for people who know that paying thousands of dollars for a short ride to the hospital is a real possibility.
Some states — Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia — have proactively worked to address the loophole about surprise ground ambulance billing. A few of these states exempt public-funded ambulance services from their consumer protections, but most do not. In both Colorado and Maine, for example, state regulators stepped in and adjudicated “reasonable and customary” rates for ground ambulance service after listening to a range of stakeholders. Insurance companies would have to assume these rates when negotiating with providers, and ambulance companies could not balance the bill beyond them.
Utah lawmakers can use this next legislative session to plug this loophole while the federal government convenes its innumerable commissions to discuss the matter. Ten states offer model legislation that Utah could adapt and adopt. This would be an immense boon to the residents of Utah and could be gifted this very year.
Valerie M. Hudson is a University Distinguished Professor at The Bush School of Government and Public Service at Texas A&M University. Her views are her own.