Key facts omitted from surprise billing debate

Mass. already provides protection; US does not

IF YOU RECEIVE a surprise out-of-network medical bill after being treated at a hospital in your insurance network, send the bill to your insurance company. Under current Massachusetts law, your financial responsibility is limited provided you are insured by a health plan regulated by the state. Only the federal government can offer the same protections that Massachusetts law provides for health plans that are regulated under ERISA, the federal insurance benefits law.

It’s extraordinary how health policy experts and reporters can get these basic facts wrong.  However, television news coverage and newspaper articles continue to ignore that Massachusetts law already protects patients from out-of-network bills and only the federal government can protect patients in ERISA plans. To date, almost every local news story on this issue has omitted this critical information.

Health insurance, medical billing, and state and federal laws regulating the health care industry are complicated. Patients are justified to feel wronged and frustrated when they receive an out-of-network medical bill for care that was provided at a hospital in their insurance network. And, patients shouldn’t be left in the middle or stuck footing the bill.

That is why Massachusetts ensures that patients are, in fact, protected and your insurance company is financially responsible for those amounts that are not part of your co-insurance, deductibles, or co-payments. And, if your insurance company gives you any pushback, point to the law that holds patients financially harmless in surprise billing situations.

You shouldn’t be surprised that Massachusetts is a leader on this front, as on most health care policy issues.  So, why have those in the news media or government omitted in public statements and in reporting reference to this protection? We are not sure of their motive, but one thing is clear: Massachusetts patients are being misled by both those in the news media and those in government who, in order to advance their agenda, ignore the existence of the law and its financial protection for patients.

As the Legislature takes up proposals for out-of-network bills, a focus on facts is essential. The dispute over out-of-network billing is primarily between insurance companies and physicians.  Patients should not become pawns, scared into thinking they are responsible for huge medical bills that, in fact, are the responsibility of their insurer.

The law in Massachusetts is clear that the health plan has the financial responsibility for additional costs when patients unknowingly receive out-of-network care at an in-network hospital or facility.

Meet the Author

David L. Gang

President, Massachusetts Society of Pathologists
For those enrolled in insurance plans regulated by the federal government, we all need to ask our representatives and senators in Washington, DC, to enact stronger safeguards, like those that already exist in Massachusetts. This much we should all be able to agree on.

Dr. David L. Gang is president of the Massachusetts Society of Pathologists. He is a practicing pathologist at Baystate Medical Center in Springfield.