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The Mechanism of Theft

The Sniper in the ER: How Surprise Billing Works

You followed the rules, went to an in-network hospital, and still got shot by a $5,000 bill from a doctor you never met. It is not an accident; it is a business model.

The Issue

The Ambush 🔒

You are responsible. You did your homework. You checked your insurer’s website. You drove past three other hospitals to get to the "In-Network" one. You lie on the stretcher, secure in the knowledge that you are covered.

Then, three weeks later, the letter arrives. $4,500. Balance Due.

How? Why? Because while the building was in-network, the doctor inside the building was not. The anesthesiologist, the radiologist, or the ER physician who spent 4 minutes looking at your chart works for a private staffing firm that does not sign insurance contracts.

This is not a clerical error. It is a sniping strategy. Private Equity firms realized that patients cannot choose their emergency doctors or anesthesiologists. You don't ask the ambulance driver, "Excuse me, is the trauma surgeon covered by Blue Cross?"

So, these firms buy up physician staffing groups and deliberately pull them out of insurance networks. They turn the hospital into a hunting ground. The hospital gets paid its negotiated rate, but the doctor sends you a "balance bill" for whatever predatory number they invented that morning.

It is extortion based on biology. They know you will pay to avoid bankruptcy, or because you are too sick to fight.

The Fix

The SAFECARE Solution: Unified Billing ✅

We do not ask the sniper to be nicer. We take away his rifle.

1. Unified Billing (Section 403) SAFECARE imposes a Single Standard Electronic Billing Format. A provider may not bill a Plan member for amounts above authorized copayments. This means the hospital sends the bill. Period. The doctors working inside the hospital must work out their payment with the hospital or the Plan directly. They cannot touch you.

2. The Participation Mandate (Section 401) To get paid at all, a provider must sign a Participation Agreement. This agreement requires them to accept Plan payment as payment in full. If they don't sign, they don't get paid. If they try to bill you directly, they face civil monetary penalties equal to 3 times the excess charge.

3. Site Neutrality (Section 402) The Plan pays based on the service, not the corporate structure. We ensure payment rates are consistent across sites, removing the incentive to play games with billing codes based on who owns the practice.

Under SAFECARE, "Out-of-Network" does not exist. If you are in America, and you are a legal resident, you are In-Network.

Criticism & Rebuttal

myth

"Doctors Will Quit"

The staffing firms will scream that if they cannot charge $5,000 for a stitch, doctors will flee the profession.

The Reality: Doctors want to treat patients, not maximize shareholder yield for a hedge fund. SAFECARE pays 100% of Medicare rates or higher, which is a fair, profitable wage for actual physicians. The only people who will "quit" are the private equity middlemen who were skimming the cream off the top.

risk

"Private Equity Collapse"

There is a legitimate risk that the highly leveraged Private Equity firms that bought these staffing groups will go bankrupt when their revenue stream is cut.

The Reality: Good. Let them fail. When they go bust, the hospitals can hire the doctors directly again, restoring the sanity of the pre-financialization era. We are not here to bail out bad bets made by Wall Street speculators.

risk

Contract Disputes

Without the ability to balance bill, hospitals and staffing groups might fight over money, potentially disrupting staffing in the short term.

The Mitigation: Section 401 mandates participation for payment. If they want access to the 330 million people covered by the Plan, they will sign the contract. The market power has shifted to the people.

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References

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