REINSTEIN: Ending an unwanted ‘surprise’ for North Carolina patients

Nobody wants to end up at the hospital or emergency room — whether it’s for unplanned care or even just a routine procedure. It’s a stressful, harrowing experience for patients and their families alike.

Thanks to an unfair practice known as surprise medical billing, the pain doesn’t end when patients are released; it can continue for weeks and months afterward as sky-high medical bills for the cost of care patients thought would be covered by insurance begin to pile up. As someone who has firsthand experience with surprise billing, I can attest that it is a real problem — one that Congress must solve the right way.

After retiring from the city of Fayetteville, serving as their assistant city manager, I obtained new insurance through my wife’s company. With my diagnosis of younger-onset Alzheimer’s, my neurologist recommended that I begin biweekly sessions for occupational and physical therapy. I was shocked to receive a bill of over $1,000 for two visits to Duke Hospital, instead of a $20 co-pay for an “in-network” visit. This is far from the kind of “surprise” any patient going through treatment needs.

Most patients don’t know how to navigate our extremely complex health care system and, like me, are left with extremely high medical bills when they receive out-of-network care — with or without their knowledge. It’s hard enough to deal with health concerns as it is; surprise billing only adds more stress for families already dealing with so much.

Fortunately, Congress is finally working to address this issue. As they do, they must ensure that whatever solution they enact is the most effective, least intrusive one possible.

Some of the legislative answers to surprise medical billing would attempt to protect patients by calling for a government-mandated benchmarking approach, which would basically put federal government bureaucrats in Washington in charge of determining the rates paid to physicians for performing out-of-network care here in North Carolina and across the country. Giving the government greater control over our health care is a treacherous road to go down.

Government benchmarking would end up underpaying many doctors for the care they provide by setting artificially lower rates that ignore the differences in cost for providing clinical services in different regions and types of facilities. That could end up costing local hospitals, emergency rooms and other health care centers hundreds of millions of dollars. This would be especially detrimental to North Carolina’s many rural hospitals, which already struggle just to keep their doors open.

Ultimately, it would be patients who would be stuck yet again if Congress implements a benchmarking solution to end surprise billing. The financial toll this approach would take could end up forcing many hospitals to consolidate or close down altogether. In addressing surprise medical billing, Congress should not create more problems than it solves — and that’s exactly what benchmarking would do.

There are, however, more practical solutions being considered in Congress — ones that would implement an Independent Dispute Resolution (IDR) in order to resolve payment disputes between health care providers and insurers. IDR would facilitate a fairer negotiation process that allows both sides to submit their desired payment amounts. An impartial, third-party mediator would ultimately decide the amount on a case-by-case basis — ensuring doctors are paid what they’re worth and providing financial security for rural hospitals in particular.

IDR has already been proven effective in New York, which adopted it back in 2015 to protect patients from surprise billing. There, it has lowered out-of-network rates, increased in-network participation, and helped keep costs for emergency care stable. North Carolina Sens. Richard Burr and Thom Tillis should help ensure whatever bill Congress passes includes the IDR framework — and not the harmful, government-mandated benchmarking approach — so we can fix this problem before it affects more patients here and across the country.