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September 19, 2018

Inside lawmakers' plan to crack down on 'surprise' medical bills

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    A bipartisan group of senators on Tuesday released a draft bill that would protect patients from surprise medical bills.

    Cheat sheet: What you need to know about the ACA

    Under the Affordable Care Act, when a patient receives emergency care, insurers are required to pay "reasonable" rates to an out-of-network provider. Then, out-of-network-doctors can bill patients for the remainder, a practice known a balance billing. However, that practice can leave patients facing high bills. For example, Kaiser Health News previously reported on an insured patient, Drew Calver, who was left with a $108,951.31 ED bill after being treated for a heart attack at an out-of-network facility—the closest emergency department (ED) to Calver's house.

    And Calver is not alone. An AmeriSpeak survey from NORC at the University of Chicago shows more than 50% of U.S. residents said they have been surprised by a medical bill they had expected their health insurance to cover.

    Draft bill details

    To address those coverage gaps, lawmakers proposed the Protecting Patients from Surprise Medical Bills Act. The draft bill would address balance billing in cases in which patients receive:

    • Emergency care services from an out-of-network provider provided at an out-of-network facility;
    • Non-emergency care services after receiving emergency care from an out-of-network facility; and
    • Non-emergency care services from an out-of-network provider at an in-network facility. 

    Under the bill, a patient who receives out-of-network emergency care would have to pay only the cost-sharing amount required for in-network emergency care under their health plans. The patient's insurer would have to cover any excess charges above the patient's cost-sharing payment.

    In addition, the bill would require out-of-network providers to notify emergency patients who have been stabilized but require additional non-emergency services that they may be responsible for the cost of out-of-network non-emergency care. Providers would have to give stable patients the option to transfer to in-network facility for non-emergency care.

    The bill would also protect patients treated by an out-of-network doctors at an in-network facility by prohibiting insurers and out-of-network providers from billing those patients at rates higher than the insurer's in-network cost sharing. The patient's insurer under the bill would be responsible for the remaining balance.

    The bill would also direct HHS' secretary to conduct a study "on the prevalence of patient cost-sharing, patients' access to care and the quality of that care, the price of insurance premiums, any change in overall health care costs, the use of emergency rooms, access to new and improved drugs and technology, [and] the adequacy of insurance networks." The bill would also direct the secretary to release a public report with recommendations to Congress on how to address surprise bills.

    Sen. Bill Cassidy (R-La.) introduced the draft bill. Sens. Tom Carper (D-Del.), Todd Young (R-Ind.), Claire McCaskill (D-Mo.), Michael Bennet (D-Colo.), and Chuck Grassley (R-Iowa), who are part of a working group to address health care price transparency, are co-sponsors of the bill, The Hill reports. 

    Cassidy said the lawmakers plan to refine the draft bill before they formally introduce the measure. He said he does not plan to push lawmakers to review the bill until January.


    Kevin Lucia, a senior research professor at Georgetown University's Center on Health Insurance Reforms, said, "Balance billing is ripe for a federal solution," because federal law does not prevent self-funded health plans from having patients pay the remaining balance of a bill when the insurer agrees to pay for care but pays the hospital less than it bills for the services provided. Lucia added that state regulations aimed at addressing balance billing also do not apply to all health plans—such as self-funded plans—which "leaves open a vast number of people that aren't covered by those laws."

    Former CMS administrator Andy Slavitt in a tweet praised the effort, saying, "This bill or something like it would accomplish a lot by ending balanced billing" (Bluth, Kaiser Health News, 9/19; Sullivan, The Hill, 9/18; Cassidy release, 9/18).

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