On Thursday, the Senate Bipartisan Working Group introduced S. 1531, the Stopping the Outrageous Practice (STOP) of Surprise Medical Bills Act, legislation aimed at addressing surprise medical bills. The bill is an updated version of a discussion draft released late last year, to which NAHU provided detailed feedback. The new version would establish a “baseball style” arbitration process for providers and insurers to settle payment disputes and would prohibit balance billing in three instances: emergency services; elective care at an in-network facility with service by an out-of-network provider; and when a patient needs additional medical care after an emergency at an out-of-network facility but can't travel elsewhere. The legislation comes a week after President Trump held a press conference alongside members of the working group to promote their efforts to address surprise billing.
Under the legislation, plans would automatically pay providers at the median in-network rate and providers would need to absorb any difference. Providers and insurers would have 30 days to appeal and initiate a dispute resolution process. The patient is completely removed from the process, and regardless of any outcome from a dispute resolution process, the patient still only owes the in-network rate. If the amount is disputed, it would initiate the “baseball style” arbitration process, where unbiased mediators certified by HHS and the Labor Department would settle the disagreements based on “commercially reasonable rates,” or the in-network rates for that geographic area rather than the actual charges. The arbitration process has been among the most controversial elements included in the proposal and has been openly opposed by the Trump Administration, which has called it “disruptive,” along with numerous other stakeholders who have pointed out its complexity and lack of transparency.
The three primary scenarios of prohibiting surprise medical bills that are addressed in the legislation are:
- 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 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: Protects patients who require additional healthcare 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: Ensures 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.
The legislative effort is being led by Senators Bill Cassidy, (R-LA), Michael Bennet (D-CO), Todd Young (R-IN), Maggie Hassan (D-NH), Lisa Murkowski (R-AK) and Tom Carper (D-DE), who comprise the working group, along with Senators Dan Sullivan (R-AK) and Sherrod Brown (D-OH) who are also cosponsoring the bill. The Senate plan was released two days after the House Energy and Commerce leadership released their own bipartisan discussion draft of “The No Surprises Act” that doesn't allow for arbitration, but instead, under certain conditions, insurers would pay providers at in-network rates even if they are out-of-network. Hospitals would also be required to have written permission from patients before letting an out-of-network physician treat them for a scheduled procedure.
Additionally, the House Ways and Means Committee has scheduled a hearing next Tuesday, May 21 on the subject. Witnesses will include Representatives Katie Porter (D-CA) and Jaime Herrera Beutler (R-WA) on an initial panel, followed by a panel of industry officials. These include James Gelfand, from the ERISA Industry Committee, Tom Nickels from the American Hospital Association, Jeanette Thornton from America's Health Insurance Plans, and Bobby Mukkamala, an otolaryngologist and board member from the American Medical Association. NAHU plans on submitting written testimony to the committee in advance of the hearing.
Given the bipartisan interest in addressing the issue in both chambers, surprise billing is among the most likely healthcare items to be considered in the current divided Congress. NAHU is committed to working with policymakers at both the federal and state levels to address the issue of surprise and balance medical bills. The NAHU legislative council includes a special balance billing working group aimed at identifying potential solutions and proposing these to policymakers. The working group recently finalized an infographic to help explain the issue of balance billing and the actions that are needed by Congress. For more information on surprise billing issues, and a look at the New York version of arbitration, listen to our podcast episode with NAHU Balance Billing workgroup member Gary Cupo and attorney John Fanburg.