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State Representative Cezar McKnight

Navigating our complex health care system can be a daunting task. Even when patients do their due diligence—researching the right health care plan for them, covering copays and meeting deductibles, finding a health care facility that is in their network—they can still be caught off-guard by unexpected costs and fees. The matter of surprise billing only makes it that much harder, and more expensive, for patients to access the care they need, when they need it.

For that reason, it is slightly comforting to know that Congress is working to address the problem of surprise billing once and for all. I say “slightly” because some of the proposed solutions that have been introduced in Congress could actually have serious, unintended consequences that reduce access to patient care, drive up costs, and undermine the ability of many hospitals, emergency rooms, and other health care clinics to provide the comprehensive, quality services and treatments upon which so many have come to rely.

Some of the measures being considered by our federal legislators would enforce a risky method to extricate patients from out-of-network billing disputes between health insurers and health care providers known as “benchmarking.” Under this approach, physicians would be paid a government-mandated benchmark amount for the out-of-network services they provide. This may prevent some patients from receiving surprise bills for care they believed would be covered by their insurance; however, it would introduce a whole host of issues for many more patients than it protects.

Benchmarking could unintentionally undermine patient access to care as well as increase costs, especially for rural South Carolinians. By setting arbitrarily low rates, doctors working in a hospital or emergency room setting would be drastically underpaid for their services. This would create hundreds of millions if not billions of dollars in losses for our state and nation’s hospitals, clinics, and emergency departments.

Smaller, rural hospitals, like Williamsburg Regional Hospital in Kingstree, would be particularly hurt by these losses—forcing them to scale back services and offerings, lay off employees, or possibly even consolidate or close down. None of these options are acceptable, and all would work to compromise patient access and the affordability of care—while also threatening the vital health care institutions that act as job providers and economic drivers for many smaller communities in South Carolina and across the country.

Congress should reject any legislative proposal that includes benchmarking and instead pursue a more rational approach outlined in other bills referred to as independent dispute resolution (IDR), which would work to protect patients from surprise billing without posing a threat to our larger health care system.

IDR is essentially a framework that enables insurance companies and health care providers to negotiate out-of-network payments in good faith. The entire process takes place online and is overseen by an independent mediator who helps make a final decision regarding payments based on the amounts provided by either party. This system incentivizes both insurers and providers to submit their best “offers” in the hopes their terms will be accepted.

As evidenced in New York, which put into place an IDR process to address this issue back in 2015, IDR works—and it works well. In New York, IDR has helped protect patients from surprise billing while increasing in-network rates and lowering out-of-network bills by 34 percent. It has also helped lower in-network emergency care costs by 9 percent. Meanwhile, California’s experience with a recently implemented benchmark approach has resulted in a decline in patient access to in-network physicians as it has incentivized insurers to cut long-standing contracts with physicians and demand drastically reduced payment levels.

Ultimately, IDR is a far more reasonable approach to ending surprise medical billing for good. That is why other states, like Washington and Texas, have also recently passed legislation to implement similar solutions. However, a piecemeal, state-by-state approach is not the most efficient way to fix this problem. That’s why it’s time for Congress to Act. More importantly, Congress must get it right.

Our congressional delegation must protect South Carolinians from surprise billing, but they also must maintain access, quality, and affordability—especially for rural parts of our state where citizens still struggle to get the care they need. I applaud Senator Tim Scott for his support of IDR and call on him and Representative Jim Clyburn to make sure that any bill passed by Congress includes the proven IDR process instead of a potentially detrimental benchmarking approach.