“What is the ‘Surprise’ in Medical Bills?”

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Patients who receive a “surprise medical bill” are surprised because they thought they had insurance, and that the insurer was supposed to pay. As Tamzin Rosenwasser, M.D., explains in the fall issue of the Journal of American Physicians and Surgeons, most people do not have true medical insurance. What they have is a pre-paid medical plan that is run by corporations that control medical services and may deny payment for them.

Full article: https://jpands.org/vol24no3/rosenwasser.pdf

Some workers have a plan that is self-funded by their employer; in this case, the “insurance company” is just a third-party administrator whose only function is processing medical bills. These ERISA plans are regulated by the U.S. Department of Labor, not by state departments of insurance. If a physician or a patient is cheated by a self-funded employer, the only recourse is in federal court, which is very expensive and unlikely to succeed.

“Health plans” try to coerce physicians into joining their “networks,” which force doctors to accept lower and lower prices and onerous constraints on referrals, laboratory testing, etc. Physicians who resist this pressure and remain independent are labeled as greedy “surprise” billers and vilified by the media and the huge third-party medical plan administrators. The Plan, which has promised to pay for all “necessary” care, may pay almost nothing for out-of-network physicians. Patients are “surprised” because the hospital leads them to believe that all services will be in-network though it knows very well that the call schedule cannot be filled with in-network doctors.

The doctor who worked all night to save a patient’s life or restore his ability to walk or chew is not only denied payment by the Plan but portrayed as the villain. Physicians who can’t get paid cannot remain in practice. And why should talented young people give up their twenties for arduous training if their work is not valued?

What is needed to fix the problem is a free market with honest pricing, not more of the government mandates and managed care that caused the problem, states Dr. Rosenwasser.

The Journal of American Physicians and Surgeons is published by the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties since 1943.