A Patient-Focused Approach for Hospitals and Providers to Combat Surprise ED Billing

Vituity CEO interview on surprise ED billing

Surprise billing is a growing problem for emergency department (ED) patients across the country. Recent news coverage by Vox, NPR, and others has highlighted stories of patients who received alarmingly high bills after visiting an ED.

As the CEO of Vituity, a national physician group that serves 6.4 million patients every year, Imamu “Mu” Tomlinson, MD, MBA, is committed to fair billing and contracting broadly across insurance networks. Vituity bills over 97% of its emergency provider claims at in-network, contracted rates—far exceeding the national average of 86%. In this conversation with Dr. Tomlinson, we’ll discuss how surprise billing impacts patients, especially those in underserved communities, and the type of legislative solution necessary to minimize, if not eliminate, this issue.

In addition to your role as Vituity CEO, you’re also a practicing emergency physician. Tell us more about your experience as a front line provider.

Tomlinson: I’ve been an emergency physician since 2003, and for the past fifteen years have lived and practiced in Selma, a small town in California’s Central Valley. Selma is in Fresno County, which has the highest percentage of individuals living in poverty out of the forty largest counties in California – 25.6 percent. This is 11 percent higher than the state average.

My practice, Adventist Medical Center Selma, operates on the thinnest margins, but we’re committed to being there for our community. Because of our rural location, additional supportive services are markedly limited. As an example, I remember a case when I first joined the practice in Selma. There was a baby who needed to be intubated. I was the only person who had experience doing this and I wasn’t on shift. They called me in to help, and it’s lucky that I only live 18 minutes from the hospital, and I was able to get in and place the breathing tube in time to help this patient. This story just illustrates that the national shortage of physicians isn’t equally distributed, and impacts smaller and more rural communities harder than most. Preserving patient access to quality, affordable medical care is one of my biggest priorities as a physician and leader.

Why is surprise billing such an important issue to you?

Tomlinson: As acute care providers, we serve patients at their most vulnerable times, during unexpected medical crises. Bottom line—they shouldn’t be caught in the middle of a payment dispute for the care that they desperately need. That’s why I’m advocating for national legislation that fixes surprise billing while improving access to care. This is especially critical for patients in our country’s underserved and economically vulnerable communities.

How are patients and providers impacted by surprise billing?

Tomlinson: Surprise billing contributes to medical debt among patients and may come as a surprise due to unexpected high deductibles and cost share responsibilities. Patients cannot always control their costs by visiting EDs of in-network hospitals. In most states, patients saddled with unexpectedly high medical bills have little recourse to appeal those charges. 

Gaps in coverage, leading to surprise billing, also have an operational and fiscal cost to the hospital and its providers. In the ED, doctors must treat every patient who walks in the door, whether or not they’re insured or in-network. However, providers rely upon insurance companies to reimburse fairly; all too often insurers offer unreasonably low rates.

How can surprise billing be reduced or eliminated without a negative consequence to patients?

Tomlinson: Most critically for our patients, fair market rates are necessary to recruit and retain quality physicians. This is especially important for practices serving economically vulnerable communities, where access to care is already limited.

Some of the proposed legislation uses Medicare rates as a benchmark for determining out-of-network payments. This approach is not fair to patients or providers for several reasons. For nearly two decades, Medicare rates have not kept pace with the general costs of inflation. Also, Medicare rates are determined by the federal budget, not by the cost of providing services. If commercial payment rates are linked to Medicare, patient access to emergency services will be restricted.

Any legislative solution must include a fair payment solution based on reasonable market rates with an independent dispute resolution (IDR) process. IDR allows for a fair process to differentiate payments, as care costs vary across communities. New York state passed legislation in 2015 that includes IDR, and as a result, consumers have saved $400 million through a 68% reduction in out-of-network claims after two years.

Besides the obvious financial burden, what other impact does surprise billing have on patients in underserved communities?

Tomlinson: It's more complex to care for very sick patients in small rural hospitals because there is limited access to specialists and often a shortage of physicians. The national shortage of physicians isn’t equally distributed. Wait times have been increasing in California and other states over the last six years, with dangerous consequences for patients. This is particularly true for underserved areas.

Rate setting in some of the current bills under debate to reduce surprise billing will disproportionately affect patients in vulnerable communities by making it harder to recruit physicians, ultimately decreasing access to care.

How does Vituity maintain its 97% in-network rate?

Tomlinson: Some providers take a significant loss on Medicaid and uninsured patients and choose a non-contracted/out-of-network strategy to make up for these losses. At Vituity, we focus on fair charges for services so that we don’t put patients in the middle of a payment dispute. This preserves patient access to care and ensures that providers and facilities are compensated fairly.

To do this, our group contracts with a wide variety of health plans in our markets, which provides as much coverage and access for patients as possible. We also have strong relationships with payers and are active advocates for fair medical billing legislation at the state and federal levels that closes coverage gaps and preserves access to care.

What is the ideal solution for surprise billing?

Tomlinson: The solution is to focus on what’s right for the patient. Patients should be protected from surprise bills related to care by providers out of their plan network, as well as unexpected personal out-of-pocket costs due to gaps in health benefit plans. 

What's best for patients is also best for hospitals and providers. Insurers must offer reasonable rates and have adequate networks so that providers receive fair payment for the care they provide without placing the financial burden on the patient. Deductibles and co-pays should be the same for all emergencies, not higher if the patient is out-of-network.

This approach will create an environment where patients have increased access to transparent, coordinated, and standardized care. Vituity is aligned with Physicians for Fair Coverage (PFC), who advocate for just such a solution at the state and national levels, and I encourage other physician leaders to get involved and help achieve the solution our patients deserve.