A new report from the Department of Health and Human Services (HHS) found that millions of Americans with private health insurance experience surprise medical billing and existing state laws have not addressed the problem adequately.
The federal No Surprises Act, which goes into effect in January 2022, was designed to address this issue.
The report, which was written by researchers in HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE), found that surprise medical bills are relatively common among privately insured patients and can average more than $1,200 for services provided by anesthesiologists, $2,600 for surgical assistants, and $750 for childbirth-related care, according to HHS.
When a person with health coverage gets care from an out-of-network provider, such as a pathologist, his or her health plan or issuer usually does not cover the entire out-of-network cost, leaving the person with higher costs than if they had been seen by an in-network provider. In many cases, the out-of-network provider may bill the individual for the difference between the charge and the amount paid by their plan or insurance, unless prohibited by state law. This is known as “balance billing.”
The ASPE report found that an estimated 18% of emergency room visits by individuals with large employer coverage resulted in one or more out-of-network bills, and this percentage varies greatly by state, ranging from a low of 3% in Minnesota to a high of 38% in Texas. Another finding in the report is that patients receiving a surprise bill for emergency care paid physicians more than 10 times as much as patients without a surprise bill for emergency care.
The ASPE report also describes how 18 states have comprehensive approaches to address surprise medical billing, while an additional 15 states have taken partial steps. These efforts include establishing standard payment rates to restrict high variation for out-of-network charges and dispute resolution processes to resolve additional payments for which patients may no longer be held responsible. However, state laws have significant limitations in protecting many patients from surprise medical billing, HHS said.
In addition, state insurance rules do not apply to self‐insured employee benefit plans, which cover 67% of workers with employer‐sponsored health coverage, HHS said.