Bipartisan Senate group introduces legislation to surprise medical billing

858

WASHINGTON —U.S. Senators Bill Cassidy, M.D. (R-LA), Michael Bennet (D-CO), Todd Young (R-IN), Maggie Hassan (D-NH), Lisa Murkowski (R-AK), and Tom Carper (D-DE), members of the Senate Bipartisan Working Group, today introduced the bipartisan STOP Surprise Medical Bills Act, legislation to protect patients from surprise medical bills. U.S. Senators Dan Sullivan (R-AK) and Sherrod Brown (D-OH) are also cosponsoring the bill.

This legislation is a product of a nearly year-long effort revising proposals and requesting feedbackon draft legislation released last September by Cassidy, Bennet, Young and Carper—and legislation introduced last Congress by Hassan.

Examples of patients receiving surprise medical bills include a patient who received a bill of nearly $109,000 for care after a heart attack, and a patient who received a bill for $17,850 for a urine test.

“Patients should be the reason for the care, not an excuse for the bill,” said Dr. Cassidy. “We have worked for almost a year with patient groups, doctors, insurers and hospitals to refine this proposal. This is a bipartisan solution ensuring patients are protected and don’t receive surprise bills that are uncapped by anything but a sense of shame.”

“This bipartisan proposal would ensure that no patient will ever again be subject to outrageously high ‘surprise bills’ as the result of a hospital visit,” said John Rother, President and CEO of the National Coalition on Health Care. “Americans should have confidence that they will be treated fairly the next time they visit an emergency room. The National Coalition on Health Care commends Senators Cassidy and Hassan for their leadership on this issue, and we urge swift consideration by the Congress. Health care is expensive enough without families being subjected to price gouging just when they are most vulnerable.

“We work every day with patients who have done everything right—have insurance, inquire about network status—but they’re still caught in the middle of a system over which they have no control. They still wind up with enormous surprise bills,” said Alan Balch, CEO of the National Patient Advocate Foundation. “We are excited to see lawmakers working together to create a more fair system for patients and their families.”

Click here to see the section-by-section.

The STOP Surprise Medical Bills Act addresses three scenarios in which surprise medical billing (also known as “balance billing”) would be prohibited:

  • Emergency services:  The bill would ensure that a patient is only required to pay the in-network cost-sharing amount required by their health plan for emergency services, regardless of them being treated at an out-of-network facility or by an out-of-network provider.
  • Non-Emergency services following an emergency service at an out-of-network facility: This bill would protect patients who require additional health care services after receiving emergency care at an out-of-network facility, but cannot be moved without medical transport from the out-of-network facility.
  • Non-Emergency services performed by an out-of-network provider at an in-network facility: The bill would ensure that patients owe no more than their in-network cost sharing in the case of a non-emergency service that is provided by an out-of-network provider at an in-network facility. Further, patients could not receive a surprise medical bill for services that are ordered by an in-network provider at a provider’s office, but are provided by an out-of-network provider, such as out-of-network laboratory or imaging services.

Providers would automatically be paid the difference between the patient’s in-network cost-sharing amount and the median in-network rate for these services, but providers and plans would have the opportunity to appeal this payment amount through an independent dispute resolution process, should they see fit. This “baseball-style” process would entail the plan and provider submitting offers to an independent dispute resolution entity that has been certified by the Secretaries of HHS and the Department of Labor. This entity would make a final decision based upon commercially-reasonable rates for that geographic area.

The patient is completely removed from this process between the provider and the plan, and regardless of any outcome from a dispute resolution process, the patient still only owes the in-network rate. States that have established an alternate mechanism for protecting patients and determining payment amounts for providers would be able to continue with those systems.

study from the Georgetown University Health Policy Institute reviewed the implementation of a similar law to address surprise medical billing in New York. New York’s law takes patients out of the middle of payment disputes between providers and plans and uses a “baseball-style” approach to settle payment disputes when the providers and plans can’t reach an agreement on their own.

The study found that state officials have seen a “dramatic” decline in consumer complaints about surprise medical billing since the law went into effect, that independent arbitrator decisions were essentially even between plans and providers, and that the vast majority of cases were resolved before needing to go to arbitration. The study points out that the state law does not cover ERISA plans, underscoring the need for federal action.