Congress should ban surprise bills before the end of the year

As Congress continues to debate the next COVID-19 relief package and the yearly spending bills, they should include bipartisan legislation in both the House and Senate to stop surprise bills. Surprise bills are unexpected bills consumers receive that are not covered by coinsurance, copays or premiums.

A patient may receive a surprise bill after going to an in-network facility—usually a hospital—expecting that the health care providers they see there are also in-network, only to find out later that is not the case. Doctors, nurses and other specialists contract with a hospital, but not necessarily with insurance companies or only with specific insurance companies. For example, if a patient is in the hospital for surgery, the hospital and surgeon may be in their insurance plan’s network, but the anesthesiologist may not be. Patients in need of emergency surgery or other emergency medical care may not even have an opportunity to ask questions about insurance coverage prior to having a procedure done.

Darren K. from Carlstadt, New Jersey, knows first-hand what it is like to face surprise bills. During his recent trip to an emergency room, he gave the hospital his insurance information and was told that the hospital and its physicians were in his insurance network. His examination revealed he had kidney stones and a blockage, so a urologist performed emergency surgery to implant a stent. After the kidney stones passed, the stent needed to be removed. Darren first learned that the urologist was out-of-network when he called for an appointment to have the stent removed. He called in-network doctors to see if they could perform the procedure, but was referred back to the original urologist who inserted the stent. He had to pay $300 because the urologist was out-of-network.

A couple of days later, Darren received a bill from the urologist for $25,000. He called the hospital and was told that because the urologist was out-of-network, the surgery was not covered by his insurance. After going back and forth with his insurance company, the insurer paid the urologist as an in-network doctor. Darren then received a revised bill for $8,000 dollars, which he could not afford. The urologist cut the bill down to $5,000, but that was still out of reach. The urologist put Darren in collections, which now shows up on his credit report and negatively impacts his credit score, meaning he may not qualify for certain loans or financing if he were to buy a new car or home.

After dealing with the bill from the urologist, Darren later found out that the anesthesiologist he had for the surgery was also out-of-network. After his insurance worked out an agreement on the anesthesiologist’s original bill, Darren was left owing $1,000, which he was fortunate enough to be able to pay despite the unexpected charge.

Darren’s story is repeated day after day in hospitals across the country. Patients need protection from surprise bills.

Legislative language with bipartisan support in both the House and Senate would protect patients from surprise bills and require a patient’s health care provider(s) and the health insurance company to work out a settlement. Protection for patients is needed because surprise bills from an emergency health situation can cause financial ruin for some families, even if they have insurance.

When patients go to hospitals that are in-network, it is reasonable for them to assume that the doctors they see are in-network as well. Surprise bills are always difficult for patients who cannot afford to pay them, but during the COVID-19 pandemic in particular, when millions of people have lost their jobs and families have had to tighten their budgets even more, paying these bills can be even more of a struggle. Congress should do the right thing and enact legislation to protect patients.


About the Author

Deborah Darcy

Deborah Darcy is the director of government relations at the American Kidney Fund.