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Surprise Medical Bills and the Abrupt Congressional Bill

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Any soul with a sound judgment may concur healthcare is not a free service. Whether considered a government-run program or a private direct pay model, it will eventually require to be reimbursed for by someone in one way or another. Although few may dissent under the presumptuousness that programs like “Medicare for all” may be free to economically disadvantaged, but in realism yet the destitute have had to bear their share of the dues at some point of time in their lives. The main problem yet isn’t necessarily who pays for the medical services, but how would or should be reimbursed for, at what rate and who determines the set value or price for that particular medical care. That marks the origin of major contention and serves as the mother of all misconceptions. Today the focus of all public media pertains to who pays for the medical care of citizens beyond trying to scrutinize how it may be deliverable under the existing legislative system on the outside of being subject to abuse and malicious overtake by the hands of those who have the least respect for human lives besides the mission of profiteering from the loopholes they were categorically granted. Every service is ultimately paid for through the billing process primarily by sending an invoice or a bill to customers; in this case for the medical care rendered to the patient or goods delivered to them. Electronic Medical billing has been the accepted methods of reimbursement practice within the United States health system and most other countries alike. Although execution of invoice is commonly processed between the consumer and the provider of the service, but in typical current healthcare system a 3rd party corporate player is often involved in the procedure. In which case the middleman has the power to control how the physicians are reimbursed. In the United States healthcare third party payers occupy the majority of the letter market. Medical billing has become a painstakingly complex task, and without proper training, physician Practices may lose revenue. With the advent of initiated merit-based reimbursement models they are even prone to penalties and disciplinary actions. Henceforth, In response to said complexity, the providers of the service (corporations including hospitals, pharmacies or diagnostics) have the experts of their own to take on the Billing responsibility for covered as well as non-covered services under the patient insurance coverage. Hence, submitting a bill for non-covered services prompt to the so-called “Surprise bill”.

Surprise bill (also called Balance billing), primarily refers to a scenario when a patient receives an unexpected bill of service after receiving care from the out of insurer network physician, facility or healthcare provider. The fact that the part or whole payment for the particular rendered service was unpaid for by the patient’s insurance and as such, receipt of such bill is unexpectedly after the clinic visit makes it inconvenient and Surprising. Balance bills are the sequel of the decades-old complex healthcare reimbursement models that are incorporated within the U.S. It’s merely designed to justify the difference between in-network versus out-of-network costs for a particular insurance carrier. In contrast, for the patient, it solely means nothing but extortion.

Even though third-party billing enactment may have started as a transparent insurance company paying for the covered medical expenses on a patient’s behalf, But over decades this recitation has turned into a sophisticated covert socioeconomic program dictating who, how, from whom, for what cost and when a patient can get medical care. The changeover from Direct billing practice into an overwhelmingly tiresome process of reimbursement is the aftermath of alienation of physicians on one hand and coup of the healthcare by corporate bureaucracy and rapacity oriented strategies on the other. In reality, the progeny with surprise bill stems from the corporate takeover of the medical practice transformation, in spite of having to a greater extent got to do with the clangor of consumerism and the dissuaded price setting.

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Price Rate setting

Concept of imposed pricing by government legislators is a common phenomenon, as is being practiced in countries across the globe. Such exercise nonetheless, has been expeditiously applied by some “constitutionally” sovereign governments with robust socialized base. Meaning, in a country where the law of the land places the power of control on the people, for the people, by the people and where free market is the constitutionally accepted driver of such economy; placing a limit on prices would mirror sealing a solitary loophole while others remain wide open, leaving the system licentious for depravity and monopoly.

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In May 2019 Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), jointly released a draft of a bill that would forestall patients from facing unexpected surprise charges after their visit to the emergency room or medical care from out of network providers. According to the associate director of the USC-Brookings Schaeffer Initiative for Health Policy, Loren Adler, This Bill is the most forceful propositions engaged at the federal level to date. It’s one of the rarest bipartisan bills. Surprisingly enough was also welcomed by President Donald Trump. The Senate seems to have adopted the bill of its own with regard to the outrageous surprise billing practice. Despite strong bipartisan efforts, still, some politicians sturdily oppose the bill. For instance Sen. Rand Paul (R-Kentucky), the most conservative member of the Senate who is very familiar with the modern era economic theory, recognizes the implications of price controls better than most other politicians trusts; the bill’s core provision aims to end surprise billing by virtually eliminating out-of-network care totally which drive creation of the perverse incentive for insurance companies to narrow their networks, even more, causing hospitals to leave networks, physicians find alternate ways to compensate for revenue deficit and ultimately cause shortage of medical care delivery service. Besides, within the midst of all and under reasoning, radical bipartisan move to stop corporate monopoly and preserve patient sovereignty has offset the controversy of its own. Irrespectively, almost everyone seems to agree that the controversial surprise bill by nature is indeed a carrier of the unethical and unfair occurrence. All also agree to the fact that the heart and soul of the line of reasoning are around the strategic approach to tackle such a fundamental predicament.

An anon group has initiated a major campaign by spending a record-breaking of $13 million on advertisements on behalf of a group called “doctor-patient unity”. The drives behind such mission presumed by members of the media are to create chaos and inconsistency within the developing fervid congressional controvert around the subject of a surprise bill. Primary agenda concerns pushing back against price setting by hospital, private equity firms, American Medical Association (AMA) and even some physician and healthcare groups. The argument is merely focusing on the fact that rate setting has the propensity to unfairly favor insurance companies.

According to a recent blog published on health affairs— within the rarity of the bipartisan efforts, we have reached a moment that politicians on both ends of the mainstream ideological spectrum agree on the vulnerability of the patients in the face of already lacking proper healthcare coverage. They also correspond that the current turmoil may potentially get out of control winding up with a limitless and unpredictable bill for services determined at the mercy of insurance companies- a knee-jerk like compensatory billing by hospitals, facilities, and consolidated groups. Forasmuch as the “surprise” prices charged are neither approved nor presented to patients in advance, they are the precipitators of indignation and extortion against the society’s most vulnerable i.e. “patients” who are forced to seek out of network care. Furthermore, since they are not bound by firsthand legal contract, affected patients are liable for every penny billed, thus subject to collection proceedings by the provider of service.

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Congress’s priority is to protect the interest of the patients by solving the reimbursement issues between physicians, healthcare providers, and insurers. And it’s distinctly pertinent to the fact that patient would be picking up the cost to whatever has not been reciprocally agreed upon by the two parties at reciprocal sides of the service conveyance. But on the other extreme enforcing rate setting may further hinder the healthcare price competition somewhat from the US market panorama. Beyond proper checks and balances, the fictitiously vicious circle of price inflation and insurer withholding to reimburse would be prone to spin out of control.

Having said that, yet— is the Federal rate setting the way to go?

Sure- the upshot seems to constitute the tipping point for the US health system. But, center for American Progress (CAP) says, rate setting and price cap is the way to go! According to CAP, United States Hospitals today capture $1 out of every $3 spent on healthcare. The hospital care costs in 2019 are projected about $1.3 trillion. Over the past decades, hospitals have been able to produce staggering profits using high prices beyond capturing market power, which has in turn grown in anticipation of even more competitiveness through consolidation, mergers, and acquisitions.

According to another source published in Health affair blog on May 2016, most hospitals lost money on every single patient care. The publication outlined Hospitals that treated the largest population of Medicare-eligible patients had much higher costs per adjusted discharge. Noteworthy is that all the latter cases were located in counties with a high proportion of uninsured patients, or in states with a dominant health maintenance organization (HMO), hence had lower profitability.

In March 2019 blog letter, a right-wing coalition group denounced the proposed rate-setting bill by the rationale that government’s excessive unconstitutional power will stamp out competition, situate private insurance industry at the convenience of vantage, thus will jeopardize patient’s commitment.

Undoubtedly, by stepping back and observing the big picture one can distinctly delineate the scenario representing the Clash of consumerism and entitlement attitude in our utterly broken partisan political system. Thus, is crucial to conceptualize the metaphorical differences between them as “apples” and “oranges”, where rate setting even though may have worked reasonably well in socialized administrative systems and by the way of governments full-fledged centralized autocratic control, but in a constitutionally capitalist framework such a mission imposes a chaotic consequences like opening a “can-of-worms”. By no means in our system fixed price enforcement without bona fide transparency and accountability deliver the same result as in Canada, Europe or the rest of the world.

One of the major challenges of our time is the public perception of the quality and the seriousness of the healthcare problem. For some is utterly oblivious that the public minds are focused in one direction and actions in another. Time and again, I have tried to convey my thoughts on the seriousness of pivotal theme. Healthcare care dilemma of our country can’t be solved utilizing the solutions of the other systems. The days for arm twisting mandates and prohibiting pledges are chapters written in the history books, pertinent to the big corporations.

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Physicians are waking up— independent practices are starting to challenge and rebound to the unfairness of the policies by creating their own consolidated groups; still leaving patients at the mercy of corporate greed. Some may refer to the perception as- “it always turns worse before getting better “but betterment is a relative phenomenon and political rhetoric is the major players of that notion.

Hypocrisy is the foe of achieving the scrupulous outcome and best result. The convenience of the straightforward efficient tactics’ comes from within- by working through what the agenda of the current system foresees. For instance, if the country is contemplating following open market policies where prices are determined by the way of consumerism, then every individual should be entitled to the Fair prospect, unprejudiced price and competitive market without corporate bigotry. At the opposite extreme of the spectrum, a closed market necessitates unconditional government takeover of the market retaining full responsibility for its commitment. To point out, the open market requires full transparency for peerless act. Nevertheless by the virtue of government inspects transparency in every step of the market process may not serve detrimental in a closed system. Ultimately, Accountability can be effectively implemented, if enough oversight exists on the market- be it through direct government possession or unmitigated open market transparency. Thus, the most important about the equitable market value of the goods and services; be it Government or the public control rests within the particular constitutionality of the given operation. Over the past decades, we have seen systems that don’t conform to one of the two extreme ends of the market spectrum. Closed market systems with partial freedom are commonly implemented in most European economies counting other countries across the world.

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In a well-structured and centralized social system, implanting capitalist programs like free market is doable though not perfect. Because a well-regulated and non-corrupt socialized system have fewer loopholes for corporations to take advantage of by means of stricter oversight. Building a Social government-run entitlement program including national health system on a fundamentally capitalist constitution not only will fail but will serve as a nidus for more monopoly and deprivation. Latter opens a new discourse; the Construct of double standard and promoting corporatism. Looking back into the history from the time corporate entities were granted the title of personhood, they merely have enjoyed the same privileges as a living person, holding the collective power and control of a group of elite whom also have the privilege of the political magic stick. With patients, physicians or in general individual interests at stake, unilateral government intervention will go so far before it fails. One can’t fight the surprise bill when countless loopholes are drilled into the core of the free market system by the first hands of the same corporate entities over aggressive lobbying and monopoly.

In a constitutionally capitalist system mandating government price-setting would resemble a game of the Russian roulette. Handcuffing the individuals while hospitals, consolidated groups, corporate insurance, and the pharmaceutical industry continue profiteering freely is absurd and unfair. Not necessarily the balance billing, government takeover of the market is a major concern, as is finding the right solution given the type of system in place. All hybrid economic systems don’t translate into the same outcome. The Capitalist scheme on top of a socialist base system will have the opposite outcome than a socialist program on top of the capitalist base framework. Corporate personification is a pseudo-capitalism mongrelized by price control. One such scenario is Medicare or the concept of Medicare-for-all.

Politicians, consolidated groups and corporations prone to payoff and bribery but people’s rights are priceless.

Empowering patients, physicians, healthcare stakeholders

More regulation is not a better ordinance. Rate setting will potentially limit the opportunity for the physicians unless the central government takes end to end control of the healthcare arcade. If enforced, the price-setting must parallel with constitutional reform. However, in the face of size, diversity and social mindset of the citizens in the United States, as well as the extreme polarity of our political mainstream such a reform is highly implausible. The unwavering solution under present-day scenario would entail full market transparency, deregulation, fair trade, corporate de-personification, and accountability. Anything short of the aforementioned is a winner for corporations, another political try for lawmakers, but the repeated revilement to individual liberty.

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Adam Tabriz
Dr. Adam Tabriz is an Executive level physician, writer, personalized healthcare system advocate and entrepreneur with 15+ years of success performing surgery, treating patients and creating innovative solutions for independent healthcare providers. He provides critically needed remote care access to underserved populations in the Healthcare Beyond Borders initiative. His mission is to Create a highly effective business model which alleviates the economic and legislative burden of independent practitioners, empowers patients and creates ease of access to medical services for everyone. He believes in Achieving performance excellence by leveraging medical expertise and modern-day technology.

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