House Surprise Billing Deal Gets Bipartisan Support in Senate

When patients get emergency care from in-network doctors, or hospital care from in-network hospitals and in-network doctors, provider network agreements spell out how much the doctors and hospitals can charge, and how much any deductibles, co-payments and coinsurance amounts will be. The agreements usually prohibit the providers from billing in-network patients for additional amounts.

When patients get care from doctors outside the plan networks, the doctors have no contractual relationship with the plans. The doctors can charge what they want to charge. The out-of-network doctors may try to bill the patients for part or all of the difference between what the plans want to pay and the billed amounts.

Traditionally, insurers, agents and brokers have called the practice of a doctor billing a patient for the difference between what the insurer will pay and the billed amount "balance billing."

Agent and broker groups have spent years trying to control balance billing.

(Related: Agent Group Fights Big Out-Of-Network Doctor Bills)

The House-Senate Deal

The PDF file containing the text of the surprise billing deal discussion draft takes up 372 pages.

The current bill short title is the "No Surprises Act."

The act would:

• Establish an independent dispute resolution (IDR) process, or arbitration process, for determinations of the rates to be paid by health plans for out-of-network care.
• Set billing standards for air ambulance services.
• Set standards for disclosures related to in-network and out-of-network deductibles and out-of-pocket limitations.
• Provide consumer protections, through external reviews, in cases involving some surprise medical bills.
• Set continuity of care standards.
• Would create a national data reporting format for employer self-insured health plan claims, to make it easier for employers to send.
• Let states require self-insured employer health plans to contribute data to state All Payer Claims Databases.
• Set standards for health plan provider directory accuracy.
• Set standards for timely patient billing.
• Establish an advisory committee on ground ambulance and patient billing.

Although the discussion draft lets providers turn to IDR organizations, to resolve disputes, rather than using standard fee schedules, the IDR organizations themselves would have to base their rulings partly on "the median in-network rate" for care, according to the official discussion draft summary.

"The IDR entity is required to consider the median in-network rate, alongside relevant information brought by either party, information requested by the reviewer, as well as factors such as the provider's training and experience, patient acuity and the complexity of furnishing the item or service, in the case of a provider that is a facility, the teaching status, case mix and scope of services of such facility, demonstrations of good faith efforts (or lack of good faith efforts) to enter into a network agreement, prior contracted rates during the previous four plan years, and other items," according to the discussion draft summary.

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