At this point, most people have either gotten stuck with a surprise medical bill they thought would be covered by their health insurance or know someone who has.
And during a two-and-a-half-hour hearing on the issue before the State Corporation Commission on Thursday, Judge Mark Christie made clear he falls firmly within the latter category.
Christie — one of three commissioners who will decide whether the state will adopt new regulations requiring hospitals to notify patients in advance if they’re likely to be treated by an out-of-network provider — repeatedly returned to the experience of a man he knows whose wife needed surgery.
As Christie tells it, the man, aware of the growing problem of surprise bills, called the hospital in advance to make sure the surgeon and anesthesiologist would be covered by his wife’s insurance.
The hospital responded that both were in network. But what the couple wasn’t told, Christie said, was that the surgery would include a visit from a hospitalist, who wasn’t in network and who later billed them for thousands of dollars.
“He didn’t think to ask about a hospitalist,” Christie said. “How would he even know to ask?”
The new regulation under review has been presented as a modest step toward addressing the problem, sometimes called balance billing, in which patients who visit in-network hospitals may be treated by out-of-network doctors who later bill patients directly for services their insurance wouldn’t cover.
The new rule would require hospitals and other providers to give patients timely notice if they’re likely to be treated by an out-of-network-provider. If they are, the patients would then have an opportunity to accept or decline that care. It would not apply to emergency treatment, where balance billing is especially common.
The proposal has the support of the insurance industry, but is facing vehement opposition from hospital and doctor groups, who would be required to cover the cost of surprise bills if they fail to provide that advance notice. Among those who have filed testimony opposing the plan: The Virginia Hospital and Healthcare Association, UVA Health, Carillion Clinic, Patient First and OrthoVirginia.
First, they argue the commission doesn’t have the legal authority to adopt the new rule. Second, they say it unfairly puts the onus on hospitals rather than insurance groups to address the problem, when, in their view, insurance companies with their complex array of plans and sub-plans are the only ones who can say for sure what they will and won’t cover.
“Insurers are the ones who have the information when it comes to what provider is in and out of their network,” said Dr. Richard Szucs, a radiologist who serves as president of the Medical Society of Virginia.
Representatives of the insurance companies countered that they have no way of knowing what providers a patient will encounter when scheduling an elective surgery. “(Patients) can call their plan all they want and they’ll never get an answer to that,” said Doug Gray, executive director of the Virginia Association of Health Plans.
Meanwhile, patient advocates like the Virginia Poverty Law Center and Virginia Attorney General’s Office of Consumer Counsel urged the commission to go further and take steps to also address surprise bills in the emergency context.
Medical providers and insurance companies have long been at odds over how to address surprise bills. Both groups say they consider the practice a scourge and both groups blame the other side for causing it. The ongoing dispute torpedoed efforts to resolve the issue with legislation earlier this year. Lawmakers had pledged to provide a fix but failed to do so.
Jill Hanken, an attorney with of the Virginia Poverty Law Center said that until the issue is resolved, patients will continue to suffer financially.
“The consumers are right in the middle of this and they’re the ones being hurt,” she said.