CONFUSED BY YOUR MEDICAL BILL?


As a physician-led organization, we believe in delivering quality, patient-centered care – not surprise bills. Envision is working with hospitals, health systems, insurance companies, legislators and advocacy groups to drive change in the healthcare system and resolve challenges with care coverage.

 

A COMPLEX AND OUTDATED SYSTEM CREATES CONFUSION


Patients are often confused and angered by their healthcare bills. It’s challenging for patients to understand the cost of the services they received, what their insurance covers and how much they are expected to pay. Confusing bills, coupled with a lack of insurance coverage transparency and understanding, can lead to unforeseen expenses and put patients in an unfair position.

The current medical reimbursement process is complicated and flawed, but it doesn’t have to be. There are opportunities to standardize billing practices, improve contracts between insurance companies and physicians and, most importantly, protect patients from unexpected gaps in care coverage.

 

THE FACTS ABOUT SURPRISE COVERAGE


Patients are being surprised by their bills. This is because complicated insurance regulations and policies designed to increase profits are leading to unexpected gaps in coverage.
 


Why do patients receive surprise bills?


They find out their healthcare plan does not cover certain medical services, physicians or facilities.


What is contributing to surprise coverage?

EMERGENCY DEPARTMENT (E.D.) CARE COVERAGE DENIALS

Some insurers are denying E.D. service claims after the fact because the patient’s condition did not qualify for emergency care. Consequently, the patient is burdened with the entire bill. This can deter patients who are experiencing life-threatening injuries from seeking the appropriate medical treatment in the E.D.

The practice violates the prudent layperson standard, which calls for insurers to pay for emergency care based on a patient’s symptoms, not the final diagnosis. In the U.S. healthcare system, E.D.s serve as an important safety net for patients. The practice of denying coverage goes against the Emergency Medical Treatment and Labor Act (EMTALA) and E.D. physicians’ responsibility to provide care to all who enter their doors.

HIGH DEDUCTIBLE HEALTH PLANS

HDHPs are becoming increasingly prevalent because they offer patients lower upfront costs but require the patient to carry much higher out-of-pocket and deductible responsibilities.

Despite the lower monthly premiums, patients can incur costly out-of-pocket expenses for care received because they have high annual deductibles that must be met before the insurer begins to pay its share.



NARROW NETWORKS

With increased frequency, insurance companies are offering plans that place tighter restrictions on which providers and healthcare facilities are in-network. Narrow networks increase the possibility of patients receiving care from out-of-network physicians or other providers.


THE IMPACT ON PATIENTS


Patients are suffering from undue financial and emotional distress. They believe health insurance will help protect them when they are most vulnerable, but when there is a lack of coverage, high deductibles and risks of coverage denials, patients are often left holding the bag. Many patients delay or forgo care, jeopardizing their health.
 


ENVISION HEALTHCARE’S COMMITMENT TO A SOLUTION


Our physicians and advanced practitioners work hard to care for our patients and communities. We are committed to making sure patients continue to receive high-quality care while driving solutions that improve the delivery of healthcare for all.
 

The solutions Envision proposes include:
 

  • A strategic commitment to in-network status whenever possible
  • Statutory clarity around payment resolution at the state and federal levels
  • A minimum benefit standard for safety net services such as emergency care
  • The appropriate use of an independent and transparent charge database

Envision is supporting state and federal legislative efforts to end surprise gaps in insurance, improve healthcare transparency and create a fair reimbursement strategy for physicians, hospitals and insurance companies.

Envision supports legislation that:

  • Protects patients from balance billing from services provided by out-of-network physicians at in-network facilities
  • Provides stronger network adequacy standards that hold insurance companies responsible for providing the appropriate access to in-network care and certain medical services
  • Establishes an independent dispute resolution process through which patients can request an independent review of their bills if they are believed to be unreasonable
  • Requires the Department of Labor to clarify that states are free under the Employee Retirement Income Security Act of 1974 to regulate payment rates to providers in self-funded health plans
  • Establishes an independent charge database to make sure physicians are fairly compensated and able to provide quality care to patients across the country
  • Establishes a standard reimbursement strategy mandating that cost-sharing payments to the physician are treated by the insurer as though they were paid to an in-network physician
  • Establishes a uniform method to determine usual, customary and reasonable (UCR) payments and enact a UCR rate that is in the 80th percentile as defined by a fair, accurate and independent charge database

PUTTING PATIENTS FIRST

As one of the nation's largest providers, we work collaboratively with patients, their communities and the entire healthcare industry to improve the delivery of care.



ADDITIONAL RESOURCES