The Surprise Insurance Gap: History, Context, and Proposed Solutions

Area of Science:

• Health Economics
• Healthcare Policy
• Patient Financial Protection

Background:

• Affordability of healthcare is a significant issue in the US, with unexpected medical bills being a primary concern for the public.
• Surprise insurance network gaps, leading to unanticipated out-of-network (OON) care, are a major cause of these unexpected medical bills.
• Hospital-based specialties, such as radiology, are frequently involved in surprise billing incidents.

Purpose of the Study:

• To address the issue of unanticipated out-of-network (OON) care and its impact on patients.
• To evaluate methods for determining appropriate reimbursement for physicians providing unexpected OON care.
• To analyze the potential consequences of different reimbursement strategies, including benchmark values and alternative dispute resolution.

Main Methods:

• Analysis of proposed methods for determining insurance reimbursement for OON services.
• Evaluation of the risks associated with using a benchmark value for service pricing.
• Assessment of the effectiveness of alternative dispute resolution (ADR) in mitigating surprise billing.

Main Results:

• Establishing a predetermined benchmark value for services carries risks, potentially disrupting negotiations and impacting care access.
• Alternative dispute resolution (ADR) is indicated as a viable method to address OON care.
• ADR processes can protect patients from unexpected OON bills and contribute to cost reduction.

Conclusions:

• The current system of surprise insurance gaps leads to significant financial burdens for patients.
• Alternative dispute resolution (ADR) offers a promising approach to managing reimbursement for unexpected OON care.
• ADR can safeguard patients, decrease the incidence of surprise OON bills, and reduce overall healthcare costs.