Surprise medical billing, also known as balance billing, happens when someone seeks care at an in-network facility or provider but receives services that are out-of-network. Many times, patients receive such care without prior knowledge or authorization.
One of the most common situations where patients might incur a surprise bill is from an emergency room visit, where patients typically have little control over the facility or provider treating them. As reported by Health Affairs, 1 in 5 patients who sought care at an emergency department received services from an out-of-network provider.
State policymakers and industry experts alike agree that consumers should not be held responsible for surprise bills from situations where patients are not given a choice, but opinions commonly diverge in the amount providers should be reimbursed. Some suggest setting a benchmark standard where reimbursement is tied to a reference point, such as the median in-network rate paid within a certain geographic area, or to a percentage of current Medicare rates.
Others recommend that the provider or facility and the insurer should first negotiate on their own to resolve payment. Should those negotiations fail, an arbiter appointed through an independent dispute resolution process would choose between proposed payments submitted by both the provider and the insurer. Still others propose a hybrid of the two.