Guest opinion: A patient-friendly fix for surprise billing


Rep. Brad Daw


Surprise medical billing has become too pervasive of an issue for Congress to ignore it anymore.

It’s a symptom of a much larger health care problem, but it’s a symptom with a fix if done properly. Surprise billing is a financial burden that patients in Utah and across the country have shouldered for far too long. Everyone involved—patients, insurance companies, and health care providers—agrees that patients should be removed from these financial disputes and shielded from receiving unwanted medical bills for out-of-network care that was beyond their control. 

Surprise billing happens after a patient unknowingly receives out-of-network care, either because they need emergency, unplanned care at an out-of-network facility or because they went to an in-network facility but received care from a physician that is not in their network. Thanks to insurance companies that are steadily shrinking their provider networks, the latter situation happens more than one might think. Whatever the case, the result is the same: patients that have already been through our system to get the care they need are slapped with outrageous bills for the cost of care not covered by their in-network cost-sharing.

The question is not should patients be protected from surprise billing—it is how to best protect them without threatening access to health care, costs, or quality for anyone. As with any issue, there are multiple viewpoints on this, which has led to multiple legislative proposals. However, some of these proposals would seek to employ a dangerous method known as benchmarking that could end up threatening patient access to quality, affordable health care in Utah and nationwide. This approach must be avoided at all costs.

Benchmarking would result in government rate-setting, a system that would allow the federal government to determine and enforce rates paid to physicians across the country. There are so many problems with that, it’s hard to know where to begin. From a medical perspective, benchmarking blatantly ignores the simple truth that the cost of providing services and care can vary dramatically in different geographical locations and from facility to facility. A one-size-fits-all approach to setting out-of-network reimbursement rates simply does not work.

What could end up happening under this model is that many doctors and physicians could simply be underpaid for the services they provide. This would add up to tremendous financial losses that get shifted to our nation’s health care facilities, many of which are operating on shoestring budgets as it is and would simply be unable to absorb these costs. That would lead to more of our hospitals closing or consolidating—in either case, diminishing access to care while leading to higher prices and increased waiting times. This would be especially devastating for rural health care, where access to quality care is scarce enough.

Benchmarking would also provide no incentive for insurance companies to negotiate to bring more providers into their networks, which is what most physicians and obviously most patients would prefer. In fact, this approach seems like it is designed strictly to benefit insurance companies as it would give them greater power to determine which physicians a patient sees and what services and treatments a patient can access. What we need is a solution that works for all parties involved.

Fortunately, Congress is considering other legislation that would seek to protect patients from surprise medical billing by using an Independent Dispute Resolution (IDR) process to resolve payment disputes between insurers and providers. IDR has been proven effective in New York, where state legislators put the process in place in 2015. Since then, in-network participation has increased while out-of-network participation and billing rates have declined. On top of that, the costs associated with providing emergency care have remained stable.

IDR is essentially a process by which both physicians and insurers are incentivized to submit their best offers through an online portal. Within 30 days, an independent mediator determines the final rate to be paid to physicians. Until that time, an interim payment based on the market value of the services provided helps ensure financial stability, particularly for rural hospitals and health care centers. No single solution is going to fully satisfy every party, but IDR is without question the approach that is fairest to everyone.

I strongly encourage the entire congressional delegation from Utah to support a legislative solution that includes IDR instead of the potentially devastating benchmarking approach. Ultimately, whatever bill Congress passes to finally address surprise medical billing must include the IDR approach in order to succeed and help protect patients, enhance transparency, and protect our nation’s entire health care system.

Rep. Brad Daw, R-Orem, is the co-chairman of the Utah Legislature’s Health and Human Services Interim Committee.