The Problem

Surprise medical billing – also known as “balance billing” – made it harder for patients to afford necessary medical care, and even bankrupted families, often when they least expected it. Prior to passage of the No Surprises Act, a doctor could bill or charge a patient for any outstanding balance after a health insurance provider paid its share, based on its contract with the doctor and hospital. Those charges became truly problematic for patients when out-of-network providers — who are not bound by contractual, in-network rate agreements with an insurance provider — billed patients for the entire remaining balance, often far exceeding the actual cost of care.

In many cases, patients would face a surprise medical bill after receiving care for a doctor they didn’t choose. For example, in 2018, Americans made roughly 130 million visits to the emergency room. Of those visits, researchers estimated that at least 1 in 6 patients received a surprise medical bill from a provider or specialist who treated them.

Not all doctors or local hospitals are the culprits behind out-of-network charges. The real issue is when clinical specialists or providers choose not to participate in health insurance providers’ networks – or if they do not meet the standards for inclusion in a network – and can then demand a blank check from patients for their services. 

These specialty providers are likely to charge substantially more than their peers in other specialties, not accept private insurance, and are not actively chosen by patients. Studies have found that out-of-network charges are most likely to come from emergency medicine physicians, anesthesiologists, radiologists, and pathologists. 

FOR EXAMPLE, ONE STUDY FOUND THAT:

Anesthesiologists charge, on average, 5.8 times the Medicare reimbursement rate.

Radiologists charge, on average, 4.5 times the Medicare rate.

Emergency medicine physicians and pathologists charge, on average, 4 times the Medicare rate.

The No Surprises Act prevents out-of-network providers from sending these charges to patients. Maintaining these protections is even more important to ensure consumers and their families have the financial security that they deserve. 

Take Action

Tell Washington it’s time to protect patients from surprise and unfair medical bills.