The coronavirus pandemic has not been kind to Georgia, which has seen an upswing in cases since the beginning of June. There are signs of economic recovery, but even the cheeriest job and wage projections can’t empty out overcrowded ICUs. And, thanks to a pressing problem known as “surprise medical billing,” patients going to an in-network facility could receive an unexpected, unwanted bill in the mail post-discharge from an out-of-network attending physician.
Fortunately, the recently passed “Surprise Billing Consumer Protection Act” proposed by State Rep. Lee Hawkins, R-Gainesville, would prohibit the practice and allow doctors and insurers to settle the remainder of the patient bill via an independent dispute resolution (IDR; aka arbitration) process. This successful model was implemented in New York in 2015 and has worked to protect patients while making sure that doctors receive their due. Gov. Brian Kemp is expected to sign this legislation and pave the way for markets and choice in health care.
Georgia is far from the only state dealing with the scourge of surprise medical bills. Other states have tried to deal with the issue, but not all have been successful. For example, in 2017 California implemented a “solution” known as rate-setting that resulted in de-facto pay cuts for doctors across the state. This policy, according to a 2019 study in the American Journal of Managed Care, resulted in the widespread consolidation of medical practices and doctors reportedly considering setting up shop in other states. Data from the California state government shows that access to care complaints in the Golden State shot up nearly 50 percent since the enactment of rate-setting.
Fortunately, New York state paved the way forward in embracing a far more promising alternative known as IDR, or arbitration. Under this system, which was implemented in 2015, patients only need to pay their in-network insurance rates for an emergency procedure. The “surprise bills” are taken out of the hands of patients and left to doctors and insurers, who must then submit competing claims to an online portal where examiners could decide which claim is the reasonable one. In the years since the new policies went into effect, New York’s law appears to have been a resounding success and patient problems have significantly decreased. A 2018 study by Yale University researchers found “the New York law reduced out-of-network billing by 34 percent and lowered in-network emergency physician payments by 9 percent.”
Insurers have long advocated for the onerous California approach, arguing that an arbitration-based system would give high-billing doctors unacceptable leverage over health care plan sponsors. In reality, the New York approach has resulted in a fair, largely even-handed process between doctors and insurers. According to a 2019 report by New York state government, health insurers actually won most (59 percent) of arbitration decisions decided in 2017 and 2018. These were only cases that had a clear winner, but often times, arbitration has resulted in a split judgment.
The report finds, “The number of cases, 33% in all, where the…[arbiter]…found in favor of the health plan for some CPT codes and the provider for others was also significant, and such split decisions had not been anticipated when the law was implemented.” It’s hard to claim that this is a lopsided process in favor of doctors when arbiters frequently side with insurers and a third of all cases are split decisions.
A 2019 Georgetown University Health Policy Institute report found that “insurers and physicians appear to be making ‘a real concerted effort’ to work out their payment disputes before filing with IDR.” This system, not California’s flawed approach, is exactly what Georgia’s health care system needs right now.
Georgia patients and doctors deserve an efficient and impartial system to finally do away with surprise medical bills. And, it looks like they just might get that.