Q: What specifically do you recommend the state’s legislature adopt in a bill? | Physicians For Fair Coverage

A: Because surprise medical bills are in fact a symptom of the larger problem - the surprise insurance gap - we are advocating for a set of legislative guidelines that solve the problem and end the need for physicians to balance bill for unexpected medical care. Our guidelines are:

  • First and foremost, for unexpected OON care, any patient out-of-pocket costs should be limited to in-network cost-sharing requirements. Effectively, any patient deductibles, co-insurance and co-pays for unexpected OON care should be applied to the in-network rates of their insurance plan.
  • An appropriate and fair minimum benefit standard should be created for out-of-network services that establishes a charge-based reimbursement schedule connected to an independently recognized and verified database, such as the FAIR Health database.
  • Physicians should no longer submit balance bills to patients for unexpected out-of-network medical care when payments are tied to this independent database. Congruently, insurers should be required to pay health care providers directly rather than sending the payment to their consumer.
  • When and if needed - as in the case when a physician’s unique background and skills are not addressed within a minimum benefit standard - mediation should occur only between the physician and the insurer, taking the patient out of the middle. Mediation should be minimally tied to an independently recognized and verified database of charges. Moreover, physicians should be allowed to initiate the mediation process and bundle claims in doing so.
  • Greater transparency should be required of insurers. Specifically, network provider directories should be easily accessible for both patients and physicians, updated immediately and completely accurate, and patients should have access to information on the average charge, reimbursement rate, and expected out-of-pocket costs for any health care service or procedure in all Geo-Zips.
  • Insurance carriers should be prevented from providing false, misleading and/or confusing information with regards to coverage and reimbursement standards. 
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