The AMA continues to seek improvements in the surprise billing legislation during the August recess and when the House returns in September. The MMA is coordinating efforts with the AMA. The 128th Maine Legislature enacted "surprise billing" legislation several years ago, P.L. 2017, Chapter 218. Physicians and others agree on this central tenet: Patients should be held harmless and not subject to bills higher than they would expect to pay had an in-network physician been available and there should be a fair system to resolve payment disputes between insurers and physicians.

In recent weeks Congress has taken significant steps in moving legislation aimed at tackling the issue of surprise billing by passing legislation out of committees in both the House and Senate. Both bills would protect patients by limiting their out-of-pocket costs to amounts they would have owed if they had been treated by an in-network physician. However, neither bill holds health insurers accountable. Both bills would resolve payment disputes between physicians and insurers by setting out-of-network payments at the median amount each insurer pays for in-network care.

Most stakeholders agree that patients should be held accountable only for their in-network cost-sharing amounts in situations where they are unable to select an in-network physician, such as in a medical emergency. Where views diverge is how to determine appropriate payment amounts for out-of-network physicians and other providers. As originally introduced, the "No Surprises Act" would have plans pay out-of-network physicians the median in-network contract amount for the service provided in that particular geographic area. Not only would that bind out-of-network physicians to contracted amounts they did not agree to accept, but it would eliminate much of the incentive for plans to contract with an adequate number of physicians in the first place. Furthermore, as the Congressional Budget Office (CBO) has noted on similar proposals, plans would have an incentive to cancel or cut contracted amounts for any physicians currently above the median rate, reducing payment for both in- and out-of-network physicians. Such a solution would tilt the advantage in negotiating fair contracts even further in the direction of plans. 

At the urging of committee members Rep. Raul Ruiz, MD (D-CA), Rep. Larry Buschon, MD (R-IN) and others, the committee adopted an amendment to provide for an independent dispute resolution process loosely based on the successful baseball-style arbitration model used in New York. Under the proposal, if either party was dissatisfied with the initial payment offer, an appeals process could be triggered that would allow an independent entity to decide between the payment offer of the plan and the physician's billed amount while considering a number of other factors related to the circumstances of the case and the training and experience of the physician. While the proposal still needs improvement, it represents an important step forward by recognizing that the resolution of these disputes requires a solution that is fair and encourages both sides to make reasonable initial payment offers and charges. 

AMA will continue to work to make improvements to these provisions over the August congressional recess and when Congress returns in September.