Insurance companies wrong on surprise medical billing

The country's largest insurance companies have spent more than $40 million this year lobbying Congress to pass legislation that would be favorable to them, but few have investigated why insurance companies are pumping millions into Congress to influence the debate taking place inside the Capitol. The answer is perhaps unsurprising: insurance companies are pursuing a policy that will allow them to boost their bottom line at the expense of patients and doctors around the country.

Congress is currently debating the best approach to stopping surprise medical bills. Unsurprisingly, the insurer-backed legislation fails to address the root cause of these bills, which can financially cripple patients who pay their premiums every month and expect their insurance plans to cover the cost of care when needed. Instead, insurers are backing legislation that will give them massive leverage over doctors and allow them to limit patient access to care in order to maximize their own profits.

Surprise medical bills occur when a patient is treated by an out-of-network doctor or other medical provider and an insurance company refuses to cover the full cost of care. In some cases, the patient might not even know they were treated out-of-network due to poor network transparency by the insurer. In other cases, the insurer might cite an unmet deductible or a technicality in their policy that only requires them to cover what is "medically necessary." This loophole has led to some extremely concerning cases in which patients were held financially responsible after suffering a major medical emergency such as a seizure.

In one case, Ethan Hassanzai, a young man with cerebral palsy, autism, and epilepsy had a severe medical episode and was rushed to an emergency room. The first doctor he saw ordered a transfer to a different medical facility that could better treat his condition. That transfer involved an air ambulance. Anthem Blue Cross, which covers Ethan's family, refused to pay for Hassanzai's claim, leaving the family with a $51,000 bill. Despite the doctor's order, the insurer told the LA Times that Anthem decided after the fact that the helicopter transfer was not "medically necessary."

Stories such as this ignited a series of Congressional efforts to end surprise medical bills. The proposals in question fall into two camps: one is known as government rate-setting or benchmarking; the other is a form of arbitration called Independent Dispute Resolution (IDR). The benchmarking proposals are supported by the insurance industry, while the arbitration proposals are supported by doctors and other medical providers. The insurance industry has spent over $40 million lobbying for their rate-setting proposal, which could result in doctor shortages and hospital closures in communities across the country.

The insurance lobby has designed their rate-setting proposal to have the government set the out-of-network reimbursement at the median in-network rate, which would rig the system in their favor and drive down compensation to unsustainable levels. Even without rate-setting, there are already reported cases of insurance companies using their near-monopoly power to offer contracts that would put hospitals out of business in some communities.

If Congress sides with the insurance lobby on surprise billing, insurers will be able to cancel contracts across the country and force physicians to accept the government fixed rate, regardless of the needs of the communities they serve. As these contracts are canceled, the reimbursement rate will continue to drop, creating a system where insurance companies further re-define their role in the health system to the ones who decide how much life-saving treatment is worth and what is medically necessary.

The potential transfer of wealth to insurance companies help explain why Aetna, Anthem, Blue Cross Blue Shield, Cigna, Humana, United Healthcare, and their trade association, America's Health Insurance Plans (AHIP), have spent over $200 million lobbying Congress over the past five years. Unfortunately, Congress is now considering what insurers call a compromise that will certainly give insurers the win they've been lobbying for, resulting in less access to care.

Meanwhile, United, Cigna, Humana, and other large insurers are telling Wall Street that it can expect higher profits for this year and next, an early celebration for a successful campaign at the expense of the American people. If we are ever going to fix healthcare in this country, we must demand that elected officials -- including Sen. Blunt, Sen. Hawley, and Congressman Smith -- stand with patients, not the insurance industry.

Dr. Ramiro Icaza (family practice), Dr. Josh Gast (internal medicine) and Dr. Lawrence Feigenbaum (dermatology) practice at Alliance Health & Dermatology in Cape Girardeau.