Practice Management

SHM pushes to protect patients from ‘surprise’ out-of-network expenses

Resolution intends to provide guidance to state lawmakers


Patients entering a hospital should not be on the hook for costs related to out-of-network insurance coverage when that hospital is in-network, according to the Society of Hospital Medicine and other major medical societies, especially if it is an emergency situation and the patient is unable to make an informed choice regarding who is administering care to them.

“We want to see it come to a resolution that does not put patients in jeopardy for paying these extra costs when they are going a hospital that is in-network, and they assume that the physicians are in-network,” Ron Greeno, MD, FCCP, MHM, president of the Society of Hospital Medicine, said in an interview.

Dr. Ron Greeno

Dr. Ron Greeno

To that end, SHM joined a group of other medical societies in introducing a resolution that ultimately passed at a summer 2017 American Medical Association delegates meeting. That resolution highlighted a number of principles related to unexpected out-of-network care, including (1) ensuring that patients are not financially penalized for receiving unexpected care from an out-of-network provider; (2) insurers must meet appropriate network adequacy standards; (3) insurers must be transparent in informing enrollees of out-of-network costs prior to scheduled procedures; and (4) insurers must provide reasonable and timely access to in-network physicians.

Other groups signing onto the resolution include the American College of Emergency Physicians, the American Academy of Orthopedic Surgeons, the American College of Radiology, the American Society of Anesthesiologists, the College of American Pathologists, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons.

“States are tackling this on a state-by-state basis and creating laws that are meant to protect patients from being placed in legal jeopardy,” Dr. Greeno said. “But you still want to maintain the rights of the health plan and the physicians to negotiate in good faith. That is basically the stance we take.”

According to Dr. Greeno, the joint resolution passed at the AMA meeting was “designed to make recommendations to states who are considering such laws.” The medical societies want to provide guidance on what to include in those laws that will make the process fair. “If you have a law that says ‘out of network doctors cannot balance bill at a hospital that is in-network,’ then the health plans have no reason to negotiate in good faith,” he said. “They will just pay those doctors whatever they feel like paying them.”

Ultimately, though, the resolution was about medical societies affirming their desire to protect patients from burdensome, unexpected bills.

“We want to make sure whatever laws are passed that they actually protect the patients while maintaining the ability of physicians and health plans to negotiate in good faith to a mutual resolution,” Dr. Greeno said.

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