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

Abstract Affordability of care is a major concern for many in the United States. Part of the affordability of care issue is unanticipated medical bills. A 2018 poll found that unexpected medical costs were the public’s greatest affordability concern, ahead of prescription drug costs and even food or rent or mortgage. An important cause of unexpected medical bills is the surprise insurance network gap. The term “surprise billing” is commonly used to describe this problem of unanticipated out-of-network (OON) care, though this is a misnomer because it is actually a “surprise insurance gap.” This gap can have significant consequences for patients and families. Hospital-based specialties like radiology have been implicated in the issue. Part of solving this problem includes determining an appropriate reimbursement for physicians who provide unanticipated OON care to patients. The two most commonly proposed methods to determine insurance company reimbursement to providers for OON services are use of a benchmark value and alternative dispute resolution. There is risk in trying to “price set” with a benchmark value. Establishing a predetermined value for services to mitigate against unexpected bills could have unintended and significant consequences, including disrupting good-faith negotiations between insurance companies and providers and impacting access to care. The data indicate that an alternative dispute resolution process can protect patients, lower the frequency of unexpected OON bills, and reduce costs.