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Time to take the ‘surprise’ out of health care bills

Emerson Hospital in Concord.JONATHAN WIGGS/GLOBE STAFF

There are few things as disconcerting as landing in the emergency room, being patched up and sent home — only to be knocked flat again when a bill arrives for services rendered by an “out-of-network” provider.

And such “surprise” bills aren’t limited to the ER. They are also showing up with an astonishing regularity after such routine procedures as colonoscopies or even births. The problem has reached such proportions nationally that Congress is at work on a bipartisan bill to address it. Closer to home, a coalition of business groups and insurance plan providers is pleading with the governor and legislative leaders to do something this year.


“Surprise” billing generally happens in one of two ways — either a patient receives care (or perhaps an ambulance ride) from a provider that isn’t part of the insured patient’s health care network, or the patient goes to an in-network facility only to unknowingly be treated by an out-of-network doctor. Few patients, after all, question whether the anesthesiologist who shows up before a colonoscopy is “in-network.” Likewise, few patients even see the radiologist who reads an x-ray or the pathologist called in after a biopsy — that is, until that unexpected bill arrives.

“Approximately one in five emergency room visits result in the potential for a surprise out-of-network bill,” according to the letter to Beacon Hill leaders by the heads of the Massachusetts Association of Health Plans, the Retailers Association of Massachusetts, the Small Business Service Bureau, the Massachusetts Association of Health Underwriters, and the state branch of the National Federation of Independent Business.

It’s not just that surprise billing is a giant pain for consumers — usually requiring calls and letters to providers, insurers, and, when all else fails, to the attorney general’s office — it’s that ultimately someone has to pay what amounts to enormously inflated costs. And those costs send health care premiums for employers and most consumers soaring.


National data, cited in the letter from those employers and insurers, show that the “surprise” charges from anesthesiologists are often about 580 percent of the Medicare rate, radiologists about 450 percent, and emergency medicine physicians about 400 percent.

Emergencies can and do happen; surprise billing should not.

The Massachusetts Health Policy Commission, which monitors health care spending, analyzed bills from 2014 and found that as many as 10,000 of them were surprise bills for out-of-network care. In the past two years, 115 patients have filed formal complaints with the attorney general’s office.

The business groups that sent the letter to the Legislature are looking for a few key changes. One is to require health care providers at least to tell patients they are about to be cared for by an out-of-network provider. That might work in nonemergency situations — but can anyone imagine the heart attacker sufferer (or a family member) saying, “Wait, let me think about?” A prohibition on balance billing of patients by providers, also suggested by the group for in-network providers and for emergency care, would surely accomplish the desired end.

And the group also supports a recommendation from the Health Policy Commission for a system of “default rates” of payment for out-of-network providers — which would effectively end the price gouging that too often exists.

“Collectively, we support setting a rate between what Medicare would pay and the average or median in-network rate,” the group wrote.


Thus far, nine states have passed some form of protection for consumers against surprise health care bills – some, like New York’s which can go all the way to arbitration, are a bit more cumbersome than others.

Last year, during a shortened session, the Legislature came close to agreeing on a bill but got hung up on what those negotiated rates for out-of-network services should be.

What shouldn’t be negotiable is allowing the current hodgepodge of a system that does a disservice to consumers, insurers, and employers alike to continue to exist another year in this state.