“Surprise billing” in health care — don’t reward the villain – Health News Today

By Dr. Marion Mass

Here are six “dots” to remember. We’ll connect them later.

  • Health insurance companies created “networks” by negotiating and contracting with physicians and hospitals to provide services to insured patients at certain rates of payment.
  • Some physicians and hospitals agreed to be “in” the networks; others didn’t or simply couldn’t because the contracts were too restrictive.
  • The supply of physicians and rural hospitals is shrinking, partly because more and more can’t stay in business on the rates that insurers offer, a trend made worse by the pandemic.
  • When a patient receives care from a physician or hospital “in” the network, the insurer pays the bills at the negotiated rate.
  • However, when a patient receives care from parties “outside” the network, the insurer isn’t obligated to pay.
  • In 1986, the Emergency Medical Treatment and Labor Act (EMTALA) became law, requiring that anyone who comes to an emergency room must be treated, regardless of insurance status or ability to pay. The penalties for flouting EMTALA are severe.