Pressure is growing on regulators—as well as insurance companies and healthcare providers—to make sure a trip to the emergency room doesn't result in a bad case of sticker shock.

Under current practices, patients who choose an ER that's in their insurance network can still get slammed with huge bills. That's because even though a hospital is in-network, the doctors who work there may not be.  

Sen. Bill Nelson, D-Fla., earlier this week asked the Federal Trade Commission (PDF) to look into these surprise medical bills, which can leave consumers on the hook for thousands of dollars.

Nelson, who cited a study published in The New England Journal of Medicine last month and written up by the New York Times, called on the FTC to investigate whether billing patients in this way is unfair or deceptive. 

“This is a national problem," says Chuck Bell, who works on consumer policy issues for Consumer Reports. “It’s going to take a lot of public pressure on Congress and regulators to step up and solve the problem. Millions of people are not protected from surprise medical bills, and we think they should be.”

Consumer Reports has been actively advocating for changes to protect consumers from out-of-network bills, particularly in emergency situations. CR has collected more than 4,000 stories from consumers struggling to pay these bills.

The problem is only growing worse as more insurance companies reduce or eliminate coverage for out-of-network services and healthcare providers contract with fewer insurers or choose not to take insurance at all.

Consumer Reports is part of a coalition of consumer advocacy organizations that pushed for laws in five states to limit surprise medical bills in ER situations. Since 2015, Illinois, Connecticut, New YorkFlorida, and California passed laws against surprise medical billing.

Consumer Reports also signed on to national legislation, the End Surprise Billing Act, introduced by Rep. Lloyd Doggett, D-Texas, last year.  

Doggett became involved in the issue "because too many insured consumers are hit with big bills after being trapped between their physicians, hospital, and insurer,” he says. Texas has one of the highest rates of surprise medical bills in the U.S.

The Doggett bill, which has 32 Democratic co-sponsors but no Republican ones, would require patients to consent before they are treated by someone not on their insurance plan.

If such consent is not possible, as might be the case in a medical emergency, the patient would have to pay only what he would have owed had the treating professional been on his insurance plan. Doggett plans to reintroduce the bill in 2017.

A Pervasive Problem

The surprise medical bill study, done by Yale University researchers who examined claims data from an insurer with clients in all 50 states, is the first to demonstrate just how widespread this problem is.

As many as one in five emergency room patients who went to an in-network hospital got a bill including charges from at least one out-of-network doctor, the researchers found.

In some areas of the country, the problem is almost impossible to avoid. Surprise out-of-network charges showed up on 62 percent of in-network ER bills in St. Petersburg, Fla., and 89 percent of such bills in McAllen, Texas.

In other cities, including Boulder, Colorado, and South Bend, Ind., these kinds of charges didn’t show up at all. That suggests, the authors write, “that surprise billing is a solvable problem.”

The study points out that doctors in non-emergency specialties are forced to negotiate with insurance companies if they don’t want the number of patients who can see them to sharply decline.

But emergency medicine is different. These doctors "aren’t chosen, can’t be avoided, and aren’t subject to the same competitive pressures that other physicians face,” says Zack Cooper, Ph.D., an assistant professor of public health and economics at Yale, who led the study. “It’s like going to dinner at a restaurant and getting an additional bill later from the person who brought you bread.”
 

Solutions Needed on Both State and Federal Levels

In his letter to the FTC, Nelson said consumers should at least be told that they will be treated by a healthcare provider who doesn’t take their insurance and how much that treatment will cost. He asked the FTC to consider whether to ban the practice of out-of-network billing in ER situations when there is no other option for treatment.

Nelson cited the case of a man named Doug Moore, who contacted Consumer Reports to complain after he was billed $1,620 for an ER trip when he became ill with stomach pains while traveling for business. Moore said he contacted his insurer on his way to the ER and was told the hospital was in his insurance network. (You can share your story with Consumer Reports here).

The FTC hasn’t said yet whether it will take action. It may not even be able to because it’s not clear whether the agency has the authority to act against insurance companies, which are governed by state regulations.

The Yale researchers say that even if other states enact the same protections as the five that already have, that won’t solve the whole problem. That's because half of consumers get health insurance through employers that self-insure and pay employee medical claims directly (other employers don't self-insure). Companies that self-insure are regulated by the federal government, not the states.

Cooper from Yale proposes this solution: States should require hospitals to offer emergency care to consumers as a bundle that includes all the treatment you get. Hospitals would negotiate with insurers for these all-inclusive services, so consumers would not be billed separately when they go to the ER.

You can learn more about Consumer Reports’ efforts—and what you can do if you end up with a surprise out-of-network charge—at our End Surprise Medical Bills site.