The legislation seeks to protect patients and establish a fair payment dispute process without interfering with existing state laws.
Leaders on both sides of the aisle in the House and Senate have announced an agreement to protect patients from “surprise medical bills” that would also establish guidelines for health care providers and health insurance companies to resolve payment disputes.
“We have reached a bipartisan, bicameral deal in principle to protect patients from surprise medical bills and promote fairness in payment disputes between insurers and providers, without increasing premiums for patients or interfering with strong, state-level solutions already on the books,” the leaders said, according to a news release posted on the House Energy and Commerce Committee website. “Under this agreement, the days of patients receiving devastating surprise out-of-network medical bills will be over. Patients should not be penalized with these outrageous bills simply because they were rushed to an out-of-network hospital or unknowingly treated by an out-of-network provider at an in-network facility. This is a win for patients and their families that will improve America’s health care system.”
Members of Congress approving the agreement include House Energy and Commerce Committee Chairman Frank Pallone Jr., D-N.J.; Ranking Member Greg Walden, R-Ore.; House Ways and Means Committee Chairman Richard E. Neal, D-Mass.; Ranking Member Kevin Brady, R-Texas; House Education and Labor Committee Chairman Robert C. Scott, D-Va.; Ranking Member Virginia Foxx, R-N.C.; Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander, R-Tenn.; and Ranking Member Patty Murray, D-Wash.
They say they are hopeful it will be signed into law in the coming days.
According to the news release, the agreement:
- Holds patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts, including deductibles, in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider.
- Prohibits certain out-of-network providers from balance billing patients unless the provider gives the patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care.
- Creates a framework that takes patients out of the middle, and allows health care providers and insurers to resolve payment disputes without involving the patient.
- Requires insurers to make a payment to the provider that is determined either through negotiation between the parties or an independent dispute resolution (IDR) process. There is no minimum payment threshold to enter IDR, and claims may be batched together to ease administrative burdens.
- Provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers.
- Empowers consumers by providing a true and honest cost estimate that describes which providers will deliver their treatment, the cost of services, and provider network status.
A section-by-section summary of the agreement is available here. ACA International will continue to follow this story.