When an issue slips off the front pages and legislation drops off the radar, people may think the problem has been solved. Not so with surprise medical bills from out-of-network providers.

If you’ve gotten one of these surprise bills, you know.

At the Quality Institute, we have not stopped advocating for a solution while hearing from every sector in health care: hospitals, consumers, physicians, insurers, unions, and employers. Everyone agrees a problem exists.

So why, after nearly a decade, is this still a problem?

The topic has emerged in the news again with a PBS NewsHour investigation. Not surprisingly, the national producers knew where to find out-of-network horror stories: New Jersey, already famous for the $9000 ER bill for a cut finger.

I hope you all can watch the program.

The investigation outlines variations of the stories we hear all the time.

• A Hillsdale man, told he needed heart surgery, confirmed that the hospital he was going to for surgery was in his insurance network. After the surgery, he received a $2200 bill from one critical care doctor in the intensive care unit who did not accept his insurance. How is the patient supposed to know one doctor in the ICU is out of network?

• A Hackensack man helping a neighbor move a glass table sliced his ankle when the glass shattered. He knew the local hospital was in his insurance network and went to the ER, which called in a plastic surgeon, who stitched him up. But while the hospital was in his network the surgeon was not. The surgeon sent the man a $6000 bill. Insurance paid about $860, leaving the man stuck with more than $5000 in bills. He, of course, assumed a surgeon working at the hospital was in the hospital’s insurance network.

Hospitals advertise themselves as one health system, and consumers see them that way. To consumers, hospitals are like department stores. You are buying from Macys whether you are buying a suit or a pillowcase or a toaster. But in reality, hospitals today are more like farmers’ markets with a multitude of purveyors, each with their own prices and agreements.

We say we have “health systems,” but we really don’t because hospitals and physicians won’t control — or claim they can’t control — the prices charged by other physicians within the same health system for services that are part of the same visit or procedure.

All of this is invisible to the patient and impossible to determine, and no one can tell the patient what price he ultimately will be charged.

Yet when lawmakers try to set a range for what is a fair price for an out-of-network procedure or test, providers argue that doing so will take away their negotiating leverage with the insurance companies.

I understand that providers need to be able to negotiate their rates with insurers, but unless there is a fair range of reasonableness put into place, or an arbitration system which fixes the bill based on reasonableness, we are leaving consumers exposed and at risk.

The patient should not pay the price (literally) for our fragmented system.

Providers are also employers and taxpayers in New Jersey and often patients themselves. They must see that the current system is bad for everyone and rewards just the few outliers who are exploiting it.

It also harms a hospital’s reputation to be featured in these news stories about patients getting outrageous surprise bills.  I am sure they would prefer to be featured in stories about their heroic and healing work.

The framework for a solution exists and has been publicly debated for over a year now.  The framework is built on five pillars:

·      Protect consumers from balance billing in emergency and surprise situations.

·      Create an arbitration system that resolves the bill quickly and cost effectively.

·      Provide consumers with information on their rights, their coverage, and the price of the care to them.

·      Save state and local tax payers money by controlling out of network costs for government employees.

·      Monitor the issue to see if legislative changes were successful or whether amendments are needed.

Consumers must be protected when they do their best to stay in network.  And arbitration is essential.  Baseball-style arbitration, where the fairer offer of the two will be chosen, has been successful in other states and deserves serious consideration. Often this method leads both parties to settle before arbitration.  Alternatively, some have suggested a fixed range of Medicare rates for these situations.

All sides need to continue seeking compromise and fix this once and for all.  Many good faith offers have been advanced and it’s important to note that most providers do not engage in abusive billing — but that doesn’t make the “surprise” any better.  Yes, this is a complex issue, but I believe the complexity has been used to avoid resolution.

Now is the time for action.  As Trenton wrestles with other key issues this summer, it should keep this one on the table too and stop the out-of-network surprises.