A study published in The New England Journal of Medicine last month found that many patients around the nation were being hit with big out-of-network bills even though they had taken care to go to hospitals that their insurers considered in-network. Such billing occurred in about 22 percent of visits covered by one large commercial insurance company alone, the study found.
Mr. Nelson, the ranking member of the Commerce Committee, became interested in the issue after reading about the research in The New York Times. The article included the case of a Florida man who received a $1,620 bill after seeking out a covered hospital when he became sick at a work conference.
The problem arises when insurance companies and emergency-room doctors fail to reach an agreement on what the doctors should be paid, even when the insurer has reached a deal with the hospital.
In his letter to the commission, Mr. Nelson called the practice “unfair and deceptive,” the legal standard for trade commission action. When patients go to an in-network hospital, they expect that the doctors who work there will also be covered by their insurance, he wrote.
“Consumers in such cases have little choice over who provides their medical care and are led to believe that all services provided in that facility are covered by their insurance plan,” he wrote.
The letter alone cannot compel the Federal Trade Commission to look into the issue, but the commission often honors the requests of the Commerce Committee and can undertake investigations at its own behest.
“Consumers deserve better than that,” said David Vladeck, a law professor at Georgetown who led the F.T.C. Bureau of Consumer Protection in recent years. “If the agency is authorized to do this investigation, my guess is the agency will energetically do this investigation.”
But even if the commission determines that the practice is problematic, it may not be able to intervene without action from Congress or state insurance regulators. Insurance companies are regulated primarily by state governments. Many hospitals are nonprofit, and nonprofit groups are also outside the commission’s reach.
“It is kind of not fair to the consumer to say, ‘You tried hard. You broke your leg. You went to an in-network hospital, and then we’re going to stick you with an out-of-network bill,’” said Fiona Scott Morton, a professor of Economics at the Yale School of Management, and one of the authors of the study in The New England Journal of Medicine.
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