Pennsylvania can do better on ‘surprise billing’ for patients | Opinion

The Pennsylvania General Assembly is considering how to address the issue of balance billing — the amount patients have to cover when their insurance company does not pay the full cost of their care. This is a common issue when, say, Pennsylvanians experience a medical emergency, have to go to a hospital out of their insurance network to address it, and end up staring down a huge medical bill.

Emergency physicians applaud the legislature for tackling this issue, as no Pennsylvanian should worry about insurance at a time of crisis.

However, the most recent attempt to address balance billing, HB 1862, would decimate emergency physicians’ ability to effectively care for all Pennsylvanians and devastate already-stressed Pennsylvania hospitals.

Under federal law, emergency physicians care for all patients without regard to insurance. HB 1862 mandates that an out-of-network emergency physician accept a payment equal to the median in-network rate for that insurance policy. By definition, half of in-network emergency physicians receive reimbursement above the median level. Knowing that emergency physicians will continue to care for all patients, insurers will quickly cut these emergency physicians out of their networks.

This will further drive down the median level of reimbursement and, as a result, decrease overall access to emergency care. Hospitals commonly subsidize emergency care due to the federal mandate to treat any patient presenting to an emergency department. As HB 1862 drives down commercial insurance reimbursement for emergency care, stressed Pennsylvania hospitals will be asked to make up the difference, a difference they cannot account for with their own financial challenges. This will only further jeopardize patient access.

Another problem with HB 1862 is how it tries to resolve insurance company-emergency physician disputes by using arbitration. Under HB 1862, the arbitrator is only permitted to determine whether the insurance company payment is accurate. However, the issue is not the accuracy, but the appropriateness of insurance company payment for emergency care that has already been provided as mandated by federal law.

As leaders in emergency medicine, one of our jobs is to make sure our emergency departments have the highest quality emergency physicians. If HB 1862 becomes law, that will become much more difficult. There is already a shortage of emergency physicians in Pennsylvania. This adverse bill will drive emergency physicians finishing training to choose to work in states with better practice conditions.

Fortunately, there is a solution that has worked in states as diverse as New York and Texas, takes patients out of the middle, and maintains a balance among emergency physicians, hospitals, and insurance companies. We should ban balance billing. Beyond that, by requiring insurance companies to pay for out-of-network emergency care at an amount to cover all reasonably necessary costs, a reimbursement standard that has been in place in Pennsylvania for over 20 years, and having an actual arbitration process between insurers and emergency physicians that looks at payment appropriateness with the loser paying arbitration costs, we can ensure that patients are protected and incentivize insurers and emergency physicians to come to their own reasonable mutual accommodation.

Emergency physicians want to protect patients and end balance billing. We want all Pennsylvanians to only worry about their health at a time of crisis. The General Assembly needs to find the right way to both protect patients and ensure that we can continue to provide the quality emergency care all Pennsylvanians deserve.

Richard Hamilton is an emergency physician in Philadelphia and a member of the Board of Directors of the Pennsylvania College of Emergency Physicians, at rh35@drexel.edu. Arvind Venkat is an emergency physician in Pittsburgh and president of the Pennsylvania College of Emergency Physicians, at president@pacep.net.