Why a new coalition is spending millions to target 'surprise' medical bills

A newly formed coalition of employers, health insurers, and a physician group is calling on Congress to establish a benchmark payment rate and implement other strategies to address so-called "surprise" medical bills.

'Surprise' medical bills, explained in 5 charts

Background: Pressure mounts for Congress to address 'surprise' bills

Pressure has been mounting in Congress to pass legislation to address surprise medical bills after President Trump last month called on lawmakers to approve such a measure.

Leaders on the House Energy and Commerce Committee last month released a draft bill to address surprise bills by setting a benchmark payment rate for out-of-network services—a proposal health care providers have said they oppose.

Separately, leaders on the Senate Health, Education, Labor, and Pensions (HELP) Committee released draft legislation to curb surprise medical bills by:

  • Implementing an arbitration process that health care insurers and providers can use to settle payment disputes for bills higher than $750;
  • Requiring hospitals that are in a health plan's network to guarantee that everyone working at the facility, as well as lab and diagnostic testing performed at the hospitals, also are in the plan's network; and
  • Setting a benchmark payment rate that insurers can use to reimburse providers who are not in their plans' networks.

Federal lawmakers have not yet decided which of the draft bills' proposals will be included in the final versions of their bills. The House Energy and Commerce Committee's Health Subcommittee on Wednesday will hold a hearing to discuss proposals to prevent patients from receiving surprise medical bills, including a proposal to cap out-of-network bills at in-network rates negotiated by regional insurers.

The Senate HELP Committee next week will hold a hearing to discuss the proposals included in its draft bill, including its proposal to establish a benchmark payment rate for out-of-network care, Inside Health Policy reports.

New coalition launches campaign targeting surprise bills

The new coalition, called the Coalition Against Surprise Medical Billing, on Tuesday launched a multi-million dollar outreach campaign intended to encourage lawmakers to pass a bill to address surprise medical bills and spotlight health care providers that send surprise medical bills to patients. The coalition is comprised of:

  • The American Benefits Council;
  • America's Health Insurance Plans;
  • America's Physician Groups;
  • The Blue Cross and Blue Shield Association; and
  • The ERISA Industry Committee.

The group specifically wants federal lawmakers to approve a measure that would require insurers to reimburse out-of-network providers based on the negotiated payment rates for the services under a patient's health plan in instances when a patient involuntarily receives care from the out-of-network provider. The proposals would require an insurer pay out-of-network providers at Medicare Part A or Part B reimbursement rates if the health plan's negotiated payment rate for the services cannot be determined.

The group also wants lawmakers to approve a measure that would require providers to disclose the network status of attending physicians and clinicians before a patient receives treatment. The coalition said the disclosure would inform patients of the possibility that they might see an out-of-network provider and give them the option to choose an in-network provider or decline treatment. The coalition said providers should give patients the disclosure at the first point of contact in nonemergency cases, but said it should not serve as a replacement for a waiver or a statement of consent from a patient.

The coalition said it opposes the use of arbitration to resolve surprise medical bills, but it does support an independent billing resolution process.

Hospital groups oppose push for benchmark payment rate

The Federation of American Hospitals (FAH) and other hospital groups have said they do not support the use of any type of benchmark payment rate to resolve surprise medical bills, and instead would prefer lawmakers to approve legislation that establishes an arbitration process.

FAH in a statement issued Tuesday said the new coalition's proposals would "create more problems than they solve and could even limit access to care." The group said, "We believe people should only be held responsible for their in-network cost-sharing amount for unavoidable out-of-network events. Once the patient is protected[,] caregivers and insurers should negotiate an appropriate payment and any new policy should provide for arbitration when necessary" (Diamond, "Pulse," Politico, 6/11; Luthi, Modern Healthcare, 6/11; Cohen, Inside Health Policy, 6/11 [subscription required]; InsuranceNewsNet, 6/11; FAH statement, 6/11).

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