As Congress debates a Phase 4 relief package in response to the economic and public health effects of the COVID-19 (coronavirus) pandemic, some lawmakers are pushing for a comprehensive, permanent solution to the problem of surprise medical bills. Most everyone agrees that COVID-19 patients should not be stuck with exorbitant, out-of-network bills if they have to be tested or treated for COVID-19 and the White House recently took some steps to prevent balance bills for COVID-19 treatment. However, Congress and the administration should ensure that any additional surprise billing measures during this emergency are narrowly focused on COVID-19 patients. Policymakers can and should resume the debate over surprise billing solutions once the pandemic subsides.
A Brief Review of the Issue
As a reminder, surprise medical bills largely occur in one of two scenarios: 1) a patient visits or is taken to an out-of-network hospital or facility during an emergency and is stuck with a large, out-of-network bill, or 2) a patient visits an in-network facility and is provided service by a doctor who’s not in their insurance network - in emergency or non-emergency situations. In these scenarios, some insurance plans will cover a portion of the bill that they have agreed to cover for out-of-network products and services, but facilities or doctors are still allowed to ‘balance bill’ the patient for the remainder of what they have charged for those products and services.
Everyone on Capitol Hill wants to prevent patients from being stuck with surprise medical bills, but stakeholders disagree over how to handle inevitable payment disputes between doctors, insurers, and hospitals. Some lawmakers prefer benchmarking all surprise medical bill reimbursements to the median in-network rate for those items or services in a given area. Insurers like this approach, but doctors do not. Other lawmakers prefer an arbitration model, in which doctors and insurers would settle payment disputes with a third party and the patient would be taken out of the middle. Doctors like this approach, and insurers do not.
NTU has advocated for a third way, which we call the contract-based alternative, in which a hospital would have to guarantee that all of their providers would either 1) contract with the same insurers the hospital does or 2) contract with the hospital, and only the hospital, for payment. Doctors could no longer balance bill patients. We see this alternative as the most fair to insurers, doctors, and hospitals, without government putting its thumb on the scale for one party or another.
Surprise Billing and COVID-19
Unfortunately, some COVID-19 patients are already being stuck with exorbitant surprise bills. The problem is particularly troublesome during this pandemic, because widespread stories of expensive medical bills for COVID-19 patients could discourage some from seeking testing or treatment for the virus.
Lawmakers could consider a legislative solution that protects COVID-19 patients from being billed at out-of-network rates for COVID-19 testing, treatment, or hospitalization. Patients should adhere to their networks whenever possible, but they should not be punished for being seen by an out-of-network provider at an in-network facility - nor should they be punished if they have to visit an out-of-network facility because their in-network facilities are at capacity.
However, any legislative or regulatory solution should be narrowly tailored to COVID-19 patients. Unfortunately, some proponents of benchmarking are pushing for their permanent solution to be included in the next deal that Congress strikes.
NTU strongly disagrees with the benchmark, and believes that it will have detrimental effects on the supply of providers across the country - particularly in rural and disadvantaged areas. This would be especially damaging during the pandemic. We prefer the contract-based alternative, but even we would ask that our preferred solution not be considered for system-wide implementation until after the pandemic subsides.
Private Sector Leading the Way
Some private companies are leading the way in the effort to ensure patients don’t receive surprise medical bills related to COVID-19. Just a few days ago, Cigna - America’s fourth largest health insurer - waived customer cost-sharing for all COVID-19 treatment through May 31, including if a patient requires a hospitalization due to COVID-19. They applied this benefit to their group health plan and Medicare Advantage customers, and encouraged the self-insured plans they manage to participate:
“This policy applies to customers in the United States who are covered under Cigna's employer/union sponsored insured group health plans, insured plans for US based globally mobile individuals, Medicare Advantage and Individual and Family Plans (IFP). Cigna will also administer the waiver to self-insured group health plans and the company encourages widespread participation, although these plans will have an opportunity to opt-out of the waiver option.”
Humana, the fifth largest insurer, made a similar decision. Aetna, the nation’s third largest insurer, has waived all cost-sharing and co-pays for COVID-19 inpatient hospital admissions. And UnitedHealthcare and Anthem, the nation’s two largest insurers, soon followed suit.
While the insurers’ decisions will not eliminate the problem of ‘balance billing’ for COVID-19 testing and treatment, these choices will significantly reduce the chance that patients are stuck with surprise bills and on the hook for thousands of dollars in out-of-pocket costs. It’s worth noting that insurers did this without a federal mandate, suggesting that the private sector can lead the way when it comes to protecting COVID-19 patients from unaffordable medical bills.
The surprise billing debate will be intense again one day in the near future, but for now policymakers should focus any fixes on the COVID-19 patients that need it most, and constructively work with major health insurers, some of which have already made moves to look out for those made vulnerable by this crisis. It’s time to focus on the immediate needs of COVID-19 patients, and not on broad, contentious fixes that could slow down the quick and immediate relief Congress needs to provide patients, providers, families, and businesses in these trying times.