Evidence-Based, Bias-Free Data Is Essential To Protect Patients From Surprise Medical Bills

WASHINGTON, D.C.—As Congress continues its efforts to advance legislation to protect patients from surprise medical bills, it is critical that important policy decisions are made on accurate and reliable research. Patients need to be taken out of the middle and protected from balance bills when emergency care is out-of-network. However, some of the proposals Congress is considering would make it exceedingly difficult for emergency departments—especially those in rural or urban underserved areas—to keep the doors open 24 hours a day, 365 days a year.

The American College of Emergency Physicians (ACEP) is especially concerned that research on surprise billing recently published in JAMA Internal Medicine is fundamentally flawed. Among other challenges, the analysis, “Assessment of Out-of-Narrow Billing for Privately Insured Patients Receiving Care in In-Network Hospitals,” fails to account for regional differences in the health care market.

The authors overstate the number of out-of-network emergency visits and exaggerate the frequency of balance billing, which may grab headlines but ultimately does a disservice to the patients left to face the challenges of inadequate insurance coverage. The authors continue from that flawed premise, playing fast and loose with the facts:

  • The authors examined 13 million emergency visit claims from only a single insurer, an oddly selective sample that represents only 1.4 percent of visits during that time frame.
  • The authors conflate claims submitted to the insurer by the physician with bills sent to the patient. From this data, it would be impossible to track the amount that the insurer may, or may not, have paid toward the claim, or to identify whether any patient ever received a bill from any of these claims at all.
  • And, perhaps to inflate the frequency of out of network emergency balance bills to suit their purpose, the authors lump in ambulance transport, which is an entirely separate billable service from the care provided in the hospital by emergency physicians.
  • Further, the study period coincides with three major changes in health care, including the passage and later implementation of the Affordable Care Act (ACA), and intentional narrowing of insurer networks, which are significant confounding variables that likely distort any analysis of access and insurance coverage.

The paper notes that a patient’s potential financial patient liability grew from $220 to $628 during the seven years analyzed. But any unbiased reader would question the lack of evidence to demonstrate whether that increase is due to the steady decrease in insurer payments, rather than any increases over time of the cost of care.

A legislative solution to end surprise billing that supports independent dispute resolution (IDR) is the proven way forward. Proposals including a workable IDR are the only options currently being discussed in Congress that limit surprise bills and truly protect patients in a way that does not jeopardize access to care or enable a lucrative give away to insurance companies.

We are hopeful that Congress can ignore biased and flawed data while recognizing that it is critical, and possible, to protect patients without hindering access to emergency services.

The American College of Emergency Physicians (ACEP) is the national medical society representing emergency medicine. Through continuing education, research, public education, and advocacy, ACEP advances emergency care on behalf of its 40,000 emergency physician members, and the more than 150 million people they treat on an annual basis. For more information, visit and

Contact: Steve Arnoff | | Twitter @EmergencyDocs

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