NM delegation can inject sanity into surprise billing

Independent dispute resolution balances patient, provider insurance interests

How about you have a medical problem, a serious procedure in the hospital, and you go home to recover?

You are weak, cannot return to work and feel terrible for the next few weeks while you try to rebuild your strength. Then, three weeks later, you get $3,000 of medical bills you know nothing about. In the past with this hospital, everything but any deductible and co-payment has been covered by your insurance.

Now, however, without your knowledge or consent, they have used an anesthesiologist and a hospitalist who are out of network, and they have billed you separately for their services. You were not informed before, during or after that they had made these choices and you had no voice at all.

How is this fair?

This is happening all over the Unites States and the vast majority of those being billed like this are not able to pay these expenses in a timely fashion. Some have charged them on a credit card and are now paying interest they can hardly afford. Ever call the providers and try to figure all of this out? Good luck. This happened to a good friend of mine within the past month.

Nobody who needs emergency medical treatment should have to worry about also being hit with excessive bills weeks or months down the road, demanding payment for the cost of care because they ended up being treated by an out-ofnetwork physician or at an out-of-network facility. Yet, thanks to a burdensome practice known as surprise medical billing, that happens all too often. In fact, some 57% of Americans have been impacted by a surprise bill at some point, according to the University of Chicago.

Congress is finally taking a closer look at how it can end the nightmare of surprise billing through federal legislation. It must act cautiously and enact a fair, balanced solution that works for all parties involved — first and foremost, patients and families, but also doctors and hospitals.

Some in Congress suggest leveraging a government-mandated benchmark to determine and set out-of-network payments to physicians. However, such an approach could also do irreparable damage to smaller, rural hospitals, threatening access and quality for patients in New Mexico and nationwide.

There is an effective solution that is outlined in some legislative proposals under consideration. It is called Independent Dispute Resolution, or IDR, and it has been working in New York to protect patients from surprise billing — while lowering out-ofnetwork bills, increasing network participation and decreasing emergency medical care costs — since the state legislature implemented it in 2015.

IDR provides a means by which both insurers and providers are able to negotiation openly and transparently to settle out-ofnetwork payment disputes in good faith. Essentially, it works much in the same manner as the process used in Major League Baseball to settle salary disputes between players and teams. Each “side” — insurance companies and providers — submit their best payment offer via an online portal and an independent, thirdparty mediator makes a decision on a final payment within 30 days. Until then, providers receive interim payments that help keep at-risk hospitals serving our rural communities financially solvent so that they may continue providing patients the vital health care services they need.

Ultimately, IDR is best for New Mexico patients, doctors, patients and families. We are fortunate to have strong leadership from Sens. Tom Udall and Martin Heinrich, as well as the entire congressional delegation from New Mexico, and it is my hope that they throw their support behind this proven approach that protects patients, their families, doctors and hospitals, and make sure IDR is included in the final legislation passed by Congress.

New Mexico patients, families, doctors, hospitals, and communities will be stronger for it.