The Protecting People From Surprise Medical Bills Act, (H.R. 3502) was introduced on June 26, 2019 by Representatives Raul Ruiz, MD (D-Calif.), an emergency physician, and Rep. Phil Roe, MD (R-Tenn.), an OB-GYN.

“Surprise billing” or “unanticipated billing” are terms being used to describe circumstances when a patient receives services from an out-of-network provider at an in-network facility and is billed for those services. Surprise bills can be very costly. There is bipartisan support for reform legislation that would no longer allow the patient to be subject to these questionable billing practices.

Example: A patient goes into an emergency room at an in-network hospital and, unable to quiz providers on the services are in-network, receives care from an out-of-network anesthesiologist. Later, the patient receives a costly bill for out-of-network care.

What solutions do physician groups support?

The Protecting People from Surprise Medical Bills Act (H.R. 3502) is modeled after New York state law. The bill would prevent out-of-network providers from billing a patient for unforeseen out-of-network care. It requires the insurance plan issuer to pay the provider a commercially reasonable rate within 30-days. If either party is dissatisfied with the payment, a 30-day period is allowed to privately negotiate the dispute. If no agreement is met, either party may trigger the independent dispute resolution (IDR) process, established by the U.S. Secretaries of Labor and Health and Human Services.

Note: IDR is “baseball-style”—the arbitrator selects either the initial provider charge or the payment that the plan initially paid the provider, whichever they deem to be more reasonable. If the parties reach a settlement prior to the completion of arbitration, they split the costs of the process. The Trump administration is opposed to arbitration. Other opponents, such as insurance companies and some employer groups, argue that arbitration would drive up overall costs and effective rates.

Alternate proposals include: capping out-of-network charges to a regional average (benchmarking); capping out-of-network charges to a percentage of relevant Medicare rates; or requiring every provider at a hospital to agree to be in-network for the networks the hospital belongs (network matching). Under network matching, hospitals would receive the payment and determine how much physicians and providers are paid.

In late June, the Senate Health, Education, Labor & Pensions (HELP) Committee overwhelmingly voted to send a wide-ranging health bill, The Lower Health Care Costs Act, to the Senate floor. The bill resolves surprise billing payment disputes by creating a benchmark payment pegged to an area's median in-network rate. Sen. Bill Cassidy, MD (R-La.) successfully proposed an amendment that would make insurers post all the physician and hospital options in their networks so patients could see their choice of doctors before deciding on a plan. Chairman Lamar Alexander (R-Tenn.) promised to work with Sen. Cassidy (R-La.) and other Senators that still want to appoint an outside arbitrator to address payment disputes. The Lower Health Care Costs Act, (S. 1895) introduced by Senator Alexander (R-TN) is the base bill for many of these negotiations. The House Energy & Commerce Committee is considering a similar proposal that includes benchmarking.