Senator Sater’s Capitol Report, for the Week of June 18: Protecting Patients From Overbilling

Sater - Column Banner - 010913How many of us have had to go to the emergency room or to the hospital only to find out later we have a huge, unexpected medical bill? Unfortunately, it’s not uncommon and often it isn’t fair or ethical. Understanding a medical bill or how your insurance pays for health care isn’t always easy. It feels like the bill and the explanation of benefits are sometimes intentionally complicated or confusing just to keep people from looking too closely at their bill or asking too many questions. If you’ve felt that way in the past, it’s not your imagination.

Last year, one of the country’s largest insurance providers announced a new policy that allowed them to evaluate emergency room visits after the fact to determine whether the visit actually warranted a trip to the ER.  Basically, the policy stated the company could deny claims when a patient goes to the emergency room for anything they don’t think is an emergency. As you can guess, this created some big problems for patients and came at a cost to those patients. One of the consequences of this policy was patients were forced to self-diagnose during possible life-threatening medical emergencies, rather than seek the medical care they need.

This isn’t the only billing problem patients face at the ER, another is what is commonly known as “surprise billing.” This is when a patient enters through the emergency room and, unknown to them, may be treated by a doctor that is out-of-network. This can happen even if it the patient goes to an in-network hospital or provider. When facing a medical emergency, patients don’t think about or may not be able to ask if the treating physician is in-network or not. Only later, and it could be months later, they find a hefty bill in the mail because of this practice of contracting with out-of-network doctors or a dispute between the insurance company and the medical provider. We all know disagreements and business disputes can happen between insurers and providers but the patient shouldn’t have to pay for it.

A bill the Missouri Legislature passed during the recent session, Senate Bill 982, aims to fix these problems and better protect patients. First off, the bill fixes the problem of insurers refusing to pay for certain ER visits by reinforcing what is known as the “prudent layperson” standard. This states that if a person with an average knowledge of medicine believes immediate medical care is required, the emergency room visit is covered by health insurance. In addition, the bill ensures a licensed physician will look over the medical file before an insurance claim can be denied. This will prevent a computer from kicking out claims based on how the hospital billed the visit. This is a simple, but necessary fix that will hold insurance companies accountable and require them to cover emergency room visits when the patient and doctor both believe it’s an emergency.

The bill also fixes “surprise billing” by requiring health care providers to charge reasonable rates for unanticipated out-of-network care, and insurance companies and providers will be required to negotiate, in good faith, to determine a reimbursement amount. After 90 days, if they fail to agree on an amount, the bill establishes a binding arbitration process. Regardless of how arbitration turns out, the patient will not be on the hook for an outrageous bill when they had no idea they were seeing an out-of-network doctor.

These issues are just a few that are driving up health care costs. The debate on health care reform must promote more competition in the marketplace; incentives for more innovation and experimentation in expanding coverage; and more transparency and personal involvement in one’s own health care. As we did with SB 982, elected officials should step up to protect patients when insurers or providers go against these goals. What we don’t need, though, is more government control of health care. As we have with Obamacare that leads to a massive one-size-fits-all bureaucracy that drives up the cost of care, costs taxpayers more and that does not provide the choice or quality of care Americans are seeking.

As always, I welcome your ideas, questions and concerns. You may contact me at the State Capitol as follows: (573) 751-1480, or by writing to Sen. David Sater, Missouri State Capitol, Room 416, Jefferson City, MO 65101.

God bless and thank you for the opportunity to work for you in the Missouri Senate.