Q. What causes the surprise insurance gap? | Physicians For Fair Coverage

A: There are factors contributing to the surprise insurance gap, which in turn leads to patients receiving surprise bills. These factors include:

  • Insufficient coverage provided by their insurers' inadequate and narrow networks. Consider that according to the Centers for Medicare & Medicaid Services (CMS), the number of insurers applying to participate in Affordable Care Act exchanges next year plunged by 38 percent compared with last year and is half of what it was in 2016. CMS also reports that upwards of 2.4 million enrollees in 40 percent of the nation's counties will have just one insurance company in their area.
  • High deductible, co-payment and co-insurance policies that are now becoming more and more popular with insurance companies. Consider that over half of people with health plans from their employers now have a deductible of $1,000 or more, up from 10 percent in 2006, according to a report from the Kaiser Family Foundation. More startling, the report found that 43 percent of insured people reported having trouble paying their deductible, up from 34 percent in 2015.
  • Take-it-or-leave-it reimbursement deals from insurers that threaten to put physicians/physician groups out of business or force physicians to practice out of network. The Department of Justice (DOJ) expressed concerns over insurers negotiating power in the suit against the proposed merger between Anthem and Cigna. Specifically, the DOJ complaint noted that the now defunct merger could reduce competition for the purchase of health care services, which could lead to lower reimbursement rates for providers, less access to medical care, reduced quality of care, and fewer value-based provider collaborations.
  • Significantly below-market standards regularly paid by insurers for care provided in out-of-network settings.

While “surprise medical bills” might make for a provocative headline, they are, in fact, a symptom of the larger problem, which is the surprise insurance gap. That is why a comprehensive solution is needed. Piecemeal approaches focused on singular symptoms of the problem will not cure the underlying disease.

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