OPINION – In the article, “Insurance Commissioner Tackles Surprise Balance Billing for Consumers,” we first acknowledge and applaud the Oregon legislature’s serious efforts to protect consumers from balance billing for emergency and surprise bills. But, we wish to clear up a consumer advocate’s misunderstanding that providers’ billed charges are “made-up numbers” that “have no relation to actual cost or actual payment,” and therefore should not be used in setting the rate for out-of-network payments.
On the contrary, the hardship that consumers face when they receive an unexpected out-of-network bill stems precisely from the fact that billed charges are not made up but real. Payment can be enforced by collection agencies, and when physicians file claim forms, they provide legal attestations that the reported charges are their actual market charges.
FAIR Health has been privileged to participate by telephone in the thoughtful, deliberative hearings before the Oregon House and Senate committees involving the consumer protection legislation, where we made ourselves fully available to provide educational assistance and answer any questions. As a transparent, conflict-free, national, nonprofit organization,
FAIR Health has been approached by officials and stakeholders in many states addressing balance billing to provide information about medical costs, both market charges and the allowed amounts set by insurers for paying claims. Those states include Arizona, Florida, Georgia, Idaho, Indiana, Nevada, New Jersey, New Mexico, Tennessee, Texas, Utah and Washington. In Connecticut and New York, our data already serve as official reference points for paying out-of-network emergency and surprise bills. FAIR Health does not offer or recommend any particular amount as a benchmark for medical fees, but instead provides neutral, objective market data based on the full range of amounts actually charged by doctors and hospitals and the rates actually allowed by insurers.
FAIR Health takes no position on what should be considered usual and customary charges or on the specifics of legislative proposals. Rather, we provide an array of current, neutral data points showing what physicians
charge for specific services in geographically specific areas, as well as the range of aggregated, de-identified allowed amounts. Many jurisdictions choose from among these varied benchmarks to help support the administration of a wide variety of state health-related programs (e.g., workers’ compensation programs, auto liability programs, programs for disabled children and neurologically impaired newborns, dispute resolution programs and health plans for state government employees). FAIR Health data have been appreciated for their breadth, depth and integrity. We apply statistical methodologies recommended and vetted by independent experts—for example, we employ standard statistical “outlier” methodologies that identify and exclude excessively high and low charges that would distort the distribution of charges. The FAIR Health repository of privately billed medical and dental claims is the largest in the country, with over 23 billion records nationwide from 2002 to the present, including over 133 million from Oregon alone. FAIR Health data are licensed by hundreds of insurers and claims administrators nationwide. In addition to providing data to policy makers and researchers, we make the data available free of charge to consumers in English and Spanish on our award-winning consumer website, fairhealthconsumer.org and consumidor.fairhealth.org, where they can look up medical and dental costs for specific services in their own locales.
FAIR Health data reflect the marketplace, and for that reason have been deemed valuable to policy makers attempting to balance the interests of key stakeholders, including medical providers and insurers, while seeking to protect consumers from surprise billing. Robin Gelburd is president of FAIR Health.
Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation’s largest repository of private healthcare claims data, comprising over 23 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth
