It’s Long Past Time to Fix “Surprise,” “Out-of-Network” Healthcare Billing

by Kellen Squire

I’ve been an unapologetic advocate for building a brighter future for Virginia’s working families; and I don’t think you can do that without discussing, in detail, forward-thinking legislation that will positively affect every single Virginian across the Commonwealth.

In that vein, this will be the first in a series of legislative “wonk” pieces I’d like to write about, discussing deficiencies in public policy, from healthcare to housing, the climate crisis to equity, that disproportionately affect working folks- and concrete ideas on how we can fix them!

I’ve spent a decade working as a nurse, both in the emergency department and in Pediatric Acute Care, which means I see Virginians in their times of greatest crisis, need, and worry, and it infuriates me to see these families hit with a surprise bill for out-of-network services they had no choice but to use. Nobody can take time to compare rates when you’re having a heart attack or stroke; nobody can check to see if a facility is in or out-of-network when they’re being airlifted to the nearest trauma facility.

And since our patients can’t do that, legislators need to step up to protect them in their most vulnerable times of need.

Compounding that, there is a crisis of rural hospitals closing in our country – almost a hundred closed since 2010. Virginia only has seven critical access hospitals left, and even keeping those has been tough. Thanks to the wins of 2017, we were able to expand Medicaid – which helped immensely – but these hospitals and communities are still under attack.

Luckily, we have a number of our federal representatives working on this right now, and whatever disagreements they have about how to get that process done, they’re all eager to keep patients “out of the scrum” in the decision making process. Patients should not be used as bargaining chips, or caught in the middle of any disagreement on how to fix this issue.

However, any legislation that relies entirely on federal “benchmark” rate-setting would drive costs for patients even higher, and potentially threaten their lives.

It’s my professional duty to provide compassionate, timely care for anyone who comes through my hospital’s doors. But while EMTALA wisely says that we cannot screen patients by their ability to pay, and must see and care for everyone, insurance companies unfortunately still have the power to take that access to care away. In many parts of Virginia- particularly rural, under-served locales – the smaller hospitals, clinics, and community health centers  are underwater financially, because they are consistently under-reimbursed by insurers. 

Many communities in our state are already in danger of losing the only health care providers they have, and federally sanctioned rate-setting essentially allows insurers to pay providers even less than they do now, according to arbitrary medians (which the insurers themselves can redefine). This will most certainly close these struggling providers down – something we cannot afford.

A federal benchmark insurance rate will only guarantee more dollars to commercial health insurance companies. The way the insurance industry is structured now, surprise bills are already a windfall for private health insurers, and rate-setting will just give them even higher profit margins on the backs of smaller providers and their patients. 

We must protect Virginia communities’ access to health care, which means opposing any legislation that relies entirely on rate-setting.

This is a solution that has to come from Washington. We can help ameliorate the problem in Richmond, but Congress must come through to help us resolve this issue, and look for comprehensive solutions that protect patients and their access to care, no matter what zip code of the Commonwealth of Virginia they live in.