Consumers Making Good-Faith Efforts to Honor Networks May Find Relief From Surprise Bills

The horror stories have come in from all over the country: the New Jersey teenager hurt in a skiing accident whose parents drove him hours to their in-network hospital, only to be hit by giant bills from an out-of-network surgeon.

A Pennsylvania couple showed up at the emergency room when the husband, in this 50s, was feeling out of sorts and suspected pneumonia. It turned out he needed open heart surgery—immediately. The couple was careful to transfer to a larger hospital that took the wife’s insurance plan. But that didn’t matter when the heart surgeon turned out to be out-of-network. The bills started showing up when her husband was is rehab.

The rise of narrow networks in managed care has put patients in the middle. Doctors and hospitals say they feel badly about it, and a commentary in JAMA Surgery even said hospitals should be compelled to address it. But these days it’s state legislators that are doing the heavy lifting, as constituents flood their inboxes with tales of five-figure bills they can’t pay. Many cases involve emergencies, as well as documented efforts to use in-network facilities—to avoid just these circumstances.

A bill in New Jersey to avoid surprise bills was recommended for passage by an independent review commission in late July. A law recently enacted in New York State protects patients if they don’t know in advance a doctor is out-of-network or if they aren’t given a choice, which happens in some emergencies or with anesthesiologists. The new law requires the provider and the insurer to reach agreement through an outside resolution process. California has been weighing a similar law, and more than a dozen states have taken some action to protect consumers.

For doctors in New York, the key is that an independent mediator has the final say on what they are paid, not the insurers. They had no more interest in fighting over payment than the patients did, according to Andrew Kleinman, MD, who spoke with Kaiser Health News.