Why “Surprise Billing” is really a surprise

why surprise billing is really a surprise

“Surprise Billing” has been a hot topic in Texas and around the country. Surprise billing occurs when a patient who has insurance receives care from an out-of-network provider and owes money out of pocket. This happens most often during surgeries or hospital stays when not all providers are in-network or during medical emergencies because EMS providers are rarely, if ever, included in-network.

The surprise in surprise billing comes because the patient doesn’t expect to see a bill that’s more than their co-pay. They have insurance, after all. The patient doesn’t expect to have to pay large medical bills on top of the monthly premiums, deductible, and co-pays they pay for health care. They especially don’t expect these bills after experiencing a medical emergency that required the response of EMS.

There seems to be a simple solution, right? 

Shouldn’t EMS providers just get in-network? If only it were that easy! 

Every provider who is in-network with an insurance provider has a contract with that insurance agency. The contract dictates the arrangements between the provider and the insurance provider’s participants. Due to the emergency nature of EMS, the patient they are responding to could have any insurance provider available – they may be a local resident or a tourist on vacation from another state. This means that the only way to avoid billing the patient would be to contract with every single insurance provider in the country – an impossible task. Further, insurance companies generally work with and through primary care physicians for the coordination of care and pre-authorization of treatment. These are not possible in emergency responses. 

Another reason patients may feel surprised that they have gotten a bill from an EMS provider is that EMS is the only first responder group that must bill for its services. Generally, the public assumes that EMS is provided for by tax revenues. This is true in part. Taxes provide for 24/7 readiness of EMS services, but not for the cost of every patient transported. Police departments are funded in full by government entities and do not bill for services. Fire departments can be funded in a variety of ways – from tax dollars to insurance billing. Some even operate on a voluntary basis to keep costs down. EMS, with its highly sophisticated rolling intensive care units and crew of medical professionals, require a stream of income from treated and transported patients that can help support their operation. However, even with the ability to bill for services, EMS providers rarely, if ever, bring in enough revenue to cover their costs of operations.

Surprise billing is a complex and nuanced issue, often intertwined with significant life events and difficult financial situations. It is important to have compassion for patients who are not expecting high bills. But it is equally important to understand the environment that insurance companies create for those they cover through their networks and methods of operation.Stay tuned to the blog or follow us on Facebook, Twitter, and LinkedIn for more insights into Surprise Billing.

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