House Health Subcommittee Takes on Surprise Medical Bills

Bipartisan draft “No Surprises Act” aims to prohibit unexpected health care charges to consumers.

6/17/2019 8:00 AM

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House Health Subcommittee Takes on Surprise Medical Bills

Several states have legislation or some form of protection for consumers from surprise medical bills, otherwise known as balance billing, however a federal solution remains in the works.

Balance billing occurs when a patient receives a bill from a health care provider to pay the difference between the provider’s charges and the amount covered by their insurance plan; often resulting from a patient receiving care from a provider out of their network. This happens in emergency situations or when a health care professional, such as a radiologist, who is not part of a patient’s network provides care at hospital in their insurance network—unbeknownst to the patient.

Federal legislators discussed this issue and draft legislation, the “No Surprises Act” during a hearing of the House Energy and Commerce Subcommittee on Health June 12.

“It is long past time for Congress to take decisive action to protect patients from the unreasonable and unacceptable practice of surprise billing,” said Energy and Commerce Chairman Frank Pallone, D-N.J., during the hearing.

Pallone and U.S. Rep. Greg Walden, R-Ore., ranking member of the committee, drafted the No Surprises Act legislation, which would, according to the hearing memorandum:

  • Prohibit balance billing and limit patient cost-sharing to the in-network amount for emergency services, and services provided by certain facility-based providers in the private insurance market;
  • Resolve the payment dispute between providers and insurers by requiring that the insurer pay at minimum the median in-network negotiated rate for the service in the geographic area where the service was delivered; and
  • Require, for scheduled care that patients receive notice and provide their consent to out of network care. If a patient does not receive adequate notice, then that provider could not balance bill the patient.

“We must protect patients from these bills, and we want to get it right. Since we released this draft last month, Chairman Pallone and I have received over 60 comment letters on this draft from stakeholders across the health care industry,” Walden said. “That feedback is critical as we work to take the patient out of these surprise billing scenarios without raising overall health care costs.”

Pallone described in his remarks that the draft No Surprises Act would resolve disputes between providers and insurers while ensuring payment.

“The discussion draft … [requires] the insurance plan to pay, at a minimum, the median in-network rate for that service in that geographic area,” Pallone said. “This ensures that in the absence of balance billing, every provider will be guaranteed some payment for their services. This would also create a predictable, transparent means of resolving these disputes between providers and insurers who have failed to contract. It would also place little to no administrative burden on states, the federal government, or the parties involved in the dispute.”  

Modern Healthcare reports mixed reactions to the No Surprises Act and other legislative measures to address balance billing.

Sherif Zaffran, chair of the board of directors, Physicians for Fair Coverage and a witness before the House Health Subcommittee, said in his prepared testimony that “a single payment standard doesn’t allow for differentiation in the marketplace based on value, quality or complexity and cost intensity of the practice location,” according to the article. “In particular, the inability to be compensated for the types of quality metrics that ultimately decrease the overall cost of care will inhibit providers who invest to create this value and drive everyone to an inefficient ‘one-size-fits-all’ reimbursement standard.”

On the Senate side, U.S. Sen. Bill Cassidy, R-La., is gaining support for his proposal with U.S. Sen. Michael Bennet, D-Colo., “that gives doctors the option to challenge the median in-network rate to an independent arbiter,” Modern Healthcare reports.

Cassidy also released draft legislation to stop balance billing in fall 2018.

The Senate Committee on Health, Education, Labor and Pensions will meet June 18, for a hearing on the “Lower Health Care Costs Act,” which includes provisions to end surprise medical bills.


Follow ACA International on Twitter @ACAIntl and @acacollector, Facebook and request to join our LinkedIn group for news and event updates. ACA International members are welcome to submit news items for possible publication to comm@acainternational.org. Visit our publications page for news submission guidelines and subscriptions to ACA Daily, Collector magazine and Pulse.

Advertising is available for companies wishing to promote their products or services. Be sure to visit the ACA Events Calendar on the Education and Training page to view our listing of upcoming CORE Curriculum and Hot Topic seminars featuring critical educational opportunities for your company.


Subscribe to ACA Daily NEWSROOM

House Health Subcommittee Takes on Surprise Medical Bills

Several states have legislation or some form of protection for consumers from surprise medical bills, otherwise known as balance billing, however a federal solution remains in the works.

Balance billing occurs when a patient receives a bill from a health care provider to pay the difference between the provider’s charges and the amount covered by their insurance plan; often resulting from a patient receiving care from a provider out of their network. This happens in emergency situations or when a health care professional, such as a radiologist, who is not part of a patient’s network provides care at hospital in their insurance network—unbeknownst to the patient.

Federal legislators discussed this issue and draft legislation, the “No Surprises Act” during a hearing of the House Energy and Commerce Subcommittee on Health June 12.

“It is long past time for Congress to take decisive action to protect patients from the unreasonable and unacceptable practice of surprise billing,” said Energy and Commerce Chairman Frank Pallone, D-N.J., during the hearing.

Pallone and U.S. Rep. Greg Walden, R-Ore., ranking member of the committee, drafted the No Surprises Act legislation, which would, according to the hearing memorandum:

  • Prohibit balance billing and limit patient cost-sharing to the in-network amount for emergency services, and services provided by certain facility-based providers in the private insurance market;
  • Resolve the payment dispute between providers and insurers by requiring that the insurer pay at minimum the median in-network negotiated rate for the service in the geographic area where the service was delivered; and
  • Require, for scheduled care that patients receive notice and provide their consent to out of network care. If a patient does not receive adequate notice, then that provider could not balance bill the patient.

“We must protect patients from these bills, and we want to get it right. Since we released this draft last month, Chairman Pallone and I have received over 60 comment letters on this draft from stakeholders across the health care industry,” Walden said. “That feedback is critical as we work to take the patient out of these surprise billing scenarios without raising overall health care costs.”

Pallone described in his remarks that the draft No Surprises Act would resolve disputes between providers and insurers while ensuring payment.

“The discussion draft … [requires] the insurance plan to pay, at a minimum, the median in-network rate for that service in that geographic area,” Pallone said. “This ensures that in the absence of balance billing, every provider will be guaranteed some payment for their services. This would also create a predictable, transparent means of resolving these disputes between providers and insurers who have failed to contract. It would also place little to no administrative burden on states, the federal government, or the parties involved in the dispute.”  

Modern Healthcare reports mixed reactions to the No Surprises Act and other legislative measures to address balance billing.

Sherif Zaffran, chair of the board of directors, Physicians for Fair Coverage and a witness before the House Health Subcommittee, said in his prepared testimony that “a single payment standard doesn’t allow for differentiation in the marketplace based on value, quality or complexity and cost intensity of the practice location,” according to the article. “In particular, the inability to be compensated for the types of quality metrics that ultimately decrease the overall cost of care will inhibit providers who invest to create this value and drive everyone to an inefficient ‘one-size-fits-all’ reimbursement standard.”

On the Senate side, U.S. Sen. Bill Cassidy, R-La., is gaining support for his proposal with U.S. Sen. Michael Bennet, D-Colo., “that gives doctors the option to challenge the median in-network rate to an independent arbiter,” Modern Healthcare reports.

Cassidy also released draft legislation to stop balance billing in fall 2018.

The Senate Committee on Health, Education, Labor and Pensions will meet June 18, for a hearing on the “Lower Health Care Costs Act,” which includes provisions to end surprise medical bills.


Follow ACA International on Twitter @ACAIntl and @acacollector, Facebook and request to join our LinkedIn group for news and event updates. ACA International members are welcome to submit news items for possible publication to comm@acainternational.org. Visit our publications page for news submission guidelines and subscriptions to ACA Daily, Collector magazine and Pulse.

Advertising is available for companies wishing to promote their products or services. Be sure to visit the ACA Events Calendar on the Education and Training page to view our listing of upcoming CORE Curriculum and Hot Topic seminars featuring critical educational opportunities for your company.


Subscribe to ACA Daily NEWSROOM

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