When insurance companies and providers can’t agree on the right price, this can leave patients stuck with the difference between what an insurance company pays and what a provider bills — which is sometimes thousands of dollars.
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It’s a challenging consumer problem particularly in the ER, since patients receiving emergency services are not in a position to shop around, and some patients are not aware that even if a hospital is in-network, the providers working at the hospital might be contractors who don’t have agreements with their insurer.
The major health care industry groups, from hospitals to physicians to insurers, all agree this is a problem but have not been able to agree on a solution.
Under a budget amendment added by Rep. Jim Butler, R-Oakwood, when an out-of-network provider gives emergency care, the provider would be paid either the in-network rate or the out-of-network rate, depending on which is the higher amount.
Butler said this is a fair way to solve the problem and protects patients, who don’t have a good way of preventing surprise bills from happening in the ER.
“The patient doesn’t have a choice. It’s an emergency,” he said.
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Butler said the bill includes an arbitration provision where if the provider doesn’t think the reimbursement was correct, they can go to mediation with the insurer, and if that doesn’t work, they can go to binding arbitration. He said the arbitration provision is based on a model already in place in New York.
A group of emergency physicians, however, say Butler’s proposal would leave them vulnerable to being shortchanged.
Dr. Brad Raetzke, president of the American College of Emergency Physicians Ohio chapter, said the association strongly objects to the amendment.
Raetzke said in a submitted statement that the problem is that the bill does not define either the in-network or the out-of-network rate, and those rates are non-transparent and under the control of the insurance plans.
“The physician has no way of knowing how these rates are determined, nor is it possible for the physician to know if he/she has been reimbursed correctly. The reality is this would cause insurance companies to drive down both in-network and out-of-network rates,” he said. “There are essentially no protections for the provider.”
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Monica Hueckel, senior director of government relations with Ohio State Medical Association, said the physician group can’t support the language in the bill.
“This issue is one that deserves a full debate and should be properly vetted through the entire legislative process, not added to the state budget without any physician input,” Hueckel said in submitted testimony.
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