A new JAMA study of almost 350,000 patients found that more than 20 percent of surgical patients received a bill for an unexpected unpaid balance averaging more than $2,000. Medical bills can be usual after emergency care visits or non-surgical hospital stays, but the study highlights how common “surprise billing” is, even when patients select in-network providers.
Billing for unreimbursed balances has been a focus for statehouses in recent years with California passing its own law in 2017. The California law created consumer protections for patients, along with an independent dispute resolution process for providers and insurers. Since then, lawmakers in Congress have also taken up the issue and in 2019 tried to get legislation passed.
But just as there was no compromise to be found among congressional legislators last year, a bipartisan aim to protect patients has not yet overcome gridlock in 2020 as the House of Representatives weighs two competing proposals on the billing issue.
Drilling down on the specifics to resolve the measures’ differences has presented a unique issue that is splitting lawmakers not by party, but by industry group — insurers or providers. Representatives on both sides are strongly advocating with lawmakers to achieve solutions most favorable to their camps.
In February of this year, two House committees released new bipartisan proposals as both parties proclaim that they want to get something done. Even so, the sides continue to debate how to best resolve payment disputes between insurers and providers.
The two current proposals trying to make headway are:
• A House Ways & Means Committee proposal that leaves out a benchmark payment mechanism that has proved a nonstarter for hospitals and specialty physician groups. Instead, the proposal includes a mediation process for when insurers and out-of-network providers cannot agree on a payment rate. (The Energy & Commerce Committee’s 2019 proposal would have decided payment rates based on benchmarks.)
• A House Education & Labor Committee proposal that blends two approaches, creating a distinct third plan. These approaches include two separate mechanisms to resolve payment disputes:
1. For amounts less than or equal to $750 (or $25,000 for air ambulance services), the Education & Labor proposal relies on a market-based benchmark of the median in-network rate of providing similar items or services in the same geographic area;
2. For amounts above $750 ($25,000 for air ambulance services), providers and payers may elect to use independent dispute resolution (IDR) to determine a fair payment amount.
Similar disputes between insurers and providers derailed attempts in 2019. The new proposals have until the May 22, 2020, deadline, when major budget bills will be voted on in Congress.
Gabriela Villanueva is CAP’s Government and External Affairs Specialist. Questions or comments related to this article should be directed to gvillanueva@CAPphysicians.com.