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Why Are We Not Surprised?

By Kevin Herrington

Board Member of My Emergency My Choice, President of Altus Healthcare, MBA and Fellow with the American College of Healthcare Executives.

The Big Insurance Lobby is Finding New Ways To Underpay For Your Care.

By law, a patient is protected by the Prudent Layperson Standard from having to pay unreasonably high out-of-network rates in emergency situations.  However, big insurance companies outright defied these laws and made it standard practice to deny, delay and decrease their payment to providers, leading to surprise bills.  Enter the “No Surprises Act”…

Backed by the support of over 40 Hospital and Physicians’ Groups , Congress overwhelmingly passed the “No Surprises Act” intended to protect patients from getting stuck with surprise medical bills resulting from gross underpayment, or outright denial to pay for your care. The law rightfully takes the patient out of the payment negotiation and was intended to set up a fair, Independent Dispute Resolution (IDR) process where an 3rd-party arbiter would consider a variety of factors to determine a fair market price insurers must pay for your care.

No Surprises Here…Unfortunately.

Surprise, surprise…Insurance companies have figured out a way to undermine the law by using their lobbying influence to change the rules in their favor.  They have pushed the Department of Health and Human Services to use “Median In-Network Rates” as a benchmark that MUST be used as the starting point for 3rd party arbitration to consider.  That means all they have to do is leverage their power as regional monopolies to underpay in uncompetitive markets…hence lowering the national median rates for services and then FORCE arbitrators to use that false number to underpay everyone across the board. This method of determining a Qualified Payment Amount was specifically rejected by your legislators who passed the No Surprises Act last year.

It would be like a judge telling an “independent jury” that they MUST consider the median sentence time for all people convicted of crime, BEFORE they hear the case of an individual to determine their innocence.  It’s inherently unfair, and a perfect example of “cronyism” at its worst!  If you don’t like the law and you have enough money and influence… just change the way the law is implemented in your favor.

In fact, this egregious miscarriage of legislation has prompted the Texas Medical Association to file a lawsuit to stop the implementation of the unfair rule. We applaud TMA for taking strong and decisive action and while their lawsuit makes its way through the process, we have already mobilized thousands of Americans to contact their legislators…asking them to put pressure on the regulators to implement the law exactly as it was intended.

“TMA supports the patient protection intent of the No Surprises Act…However, TMA’s lawsuit challenges one component of the administration’s rule that ignores congressional intent and unfairly gives health plans the upper hand in establishing payment rates when a patient receives care from an out-of-network physician, oftentimes in an emergency.”

— TMA President E. Linda Villarreal, MD

Why Should You Be Concerned?

The good news is that patients should still be protected from being directly charged for services gone underpaid by insurers.  The bad news is that your healthcare providers, especially those in emergency departments, will continue to be underpaid and run deficits for the services they provide. That could spell disaster for our national emergency care network. After almost 2 years of the pandemic, your healthcare providers are overworked and underpaid, while insurance companies continue to collect record profits. 

Implementation of rules like this will lead to fewer physicians, nurses and specialists wanting to work in Emergency care, longer waits at emergency rooms, and ultimately higher rates being charged for services to make up the difference.

Is it fair that “The People” have to fight for a critical patient protection law to pass, only to see it nerfed by regulatory bureaucracy? No it’s inherently unfair.  But, if we don’t continue to assert our rights as patients and healthcare providers, then we doom ourselves to a “healthcare” future controlled by corporate bureaucrats who don’t care about your health!

Take action by completing the form on this page, which will locate your Federal elected officials and send them a letter on your behalf.  Together, lets put…

#PatientsOverProfits

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