Podcast: Tom Talks Surprise Medical Billing

Tom joins us to give us the run down on surprise medical billing. We cover what it is, how it happens, and what is being done to help patients.

An inevitability of life is surprises. Some surprises bring us joy, like finding a long-forgotten $5 bill in your jeans on laundry day. Some come in the form of a strange and shocking line on a hospital bill, where you discover the anesthesiologist for the surgery you received at an in-network hospital is not rated in-network. This is what’s known as surprise or balance billing.

Surprise/Balance billing is a common occurrence, as facilities and specialists contract separately, and is sometimes unavoidable. You may have no choice but to visit an out-of-network facility and you can’t really grill the facility on the network contracts of specialists if you’re unconscious, for example.

In this installment of Tom Talks, Tom delves into some of the proposed changes to Surprise/Balance billing.

Here are some highlights from the podcast:

The first of three proposed changes on the federal level comes from Lamar Alexander.  (5:10) “He is proposing that there be a standard in-network guarantee for both doctors and hospital facilities. This is telling all of those specialists…even though they are out-of-network specialists, they will be guaranteed only in-network payments.”

The second come from Raul Ruiz, a doctor himself. (6:03) “He is proposing an arbitration model, whereby the carriers and the doctors will agree that the doctor will receive 80% of billed charges.”

The third proposed model is (7:18) “the Benchmark model, and that is where you establish a median pricing…They take what they are going to consider to be the median price, which means that you take the high[est] rate…and the low[est] rate…and you throw them both out…whatever is in the middle, that’s what the doctor or hospital is going to be receiving.”

Two systems have been proposed on the Texas state level. (9:13) “One would be a mediation program, whereby a middle ground would be agreed upon between the health plan…and the facility.” Tom clarifies that this would include a third-party mediator. The other system would be (9:56) “an arbitration system, but here the arbitration system would be between the health insurance carrier and now the doctors…There would be and arbitrator. The Arbitrator would listen to what the [health insurance plan] wants to charge in agreement with the hospital and what the provider wants to charge, and then [they have] to choose one or the other.”

President Trump has also acted into his own, with an executive order. (11:26) “In that order, it requires the hospitals to provide ‘standard charge pricing’ on 300 shoppable items and services that hospitals perform.”

Speaking of surprises, Tom revealed a surprising fact that could turn hospitals and doctors to proposed Medicaid for all. (16:10) “Medicare and Medicaid are now reimbursing at a much higher percentage than the commercial business is.”

Press play on the podcast to learn more about these changes, pros, cons, proponents, and opponents.