SCC’s surprise billing regulation falls short

By David E. Fosnocht, MD

Surprise medical billing has become a national problem for patients, and it requires a national solution. Piecemeal attempts that address only small aspects of the issue—like the State Corporation Commission’s proposed regulation (“SCC hearing on reg designed to protect against surprise medical bills,” Augusta Free Press, August 17, 2019)—will not do the trick.

When Congress returns to session in September, they need to solve this problem the right way: by passing federal legislation that separates patients from out-of-network billing disputes between physicians and insurers while growing provider networks so surprise billing never happens in the first place.

Unfortunately, the SCC’s proposed solution, which would require medical facilities to notify patients that they could be treated by an out-of-network physician, is far from practical. What’s more, it doesn’t even apply to emergency care. ER physicians often find it the most difficult to negotiate fair contracts with insurance companies. As a result, we are typically engaged in long and drawn out negotiations to BE included in insurers’ networks.

Congress can fix this situation by passing a solution using the Independent Dispute Resolution (IDR) process in order to settle individual cases of out-of-network billing disputes. IDR would create a framework for insurers and physicians to negotiate fair payments based on the market value of services provided. This would provide a transparent, fair process that does not give too much power to one side of the equation- insurers or doctors.

On top of that, the IDR process would give insurance companies more incentive to negotiate fair contracts in order to grow, rather than shrink, their provider networks. This is far and away a better solution than other bills that propose government benchmarking using internal insurance rates as the solution to surprise billing. Benchmarking would lead to an unfair playing field, tipping the scales solely in favor of the insurance industry and jeopardizing patient access to care.

Congress should focus on enacting a strong, truly IDR-focused solution to end surprise billing the right way—and Senator Warner should help make sure it happens this year.

David E. Fosnocht, MD, specializes in emergency medicine at Augusta Health.