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News & Press: Advocacy & Health Policy

Contact Congress: Stop Surprise Medical Billing of Your Patients

Tuesday, September 17, 2019  
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Unanticipated, or surprise, medical bills can arise when patients reasonably believe the care they received would be covered by their health insurer but it was not. Such situations may include when a patient receives care in an emergency from physicians or facilities who have not been contracted by their health insurance company; or when a patient receives scheduled care from an in-network physician at an in-network facility but other participants in the episode of care, whom the patient did not have an opportunity to choose, are not in their insurer’s network.


Currently, Congress is considering multiple pieces of legislation that aim to address the issue of surprise billing. There is broad agreement that any legislation should protect patients from the failure of their health insurer to provide an adequate network of physicians. Patients who experience true “surprise bills” should be responsible only for the cost-sharing amounts that would have applied if their provider had been in-network.


While out-of-network physicians are willing to forgo the ability to balance bill patients for amounts not covered by their patient’s insurance company, there must be a fair mechanism for settling disputes between physicians and plans over the appropriate payment amount. At no point should negotiated, discounted in-network rates be used as a benchmark to determine fair payment to out-of-network physicians, and at every point commercial data from independent sources should inform the payment standard.


When the minimum payment from the payer for out-of-network care is insufficient, an independent dispute resolution (IDR) process should be developed to determine a fair payment by the health insurance company for the care provided. The IDR should be structured with clear factors that an arbiter, familiar with health care billing, must consider when deciding such as the complexity of the case, the experience of the physician, and the rate that physicians charge for that service in the area. 


Such an IDR, or appeals, process was included in legislation adopted by the House Committee on Energy and Commerce. Congress should continue to improve this proposal by requiring the  independent third party to consider additional information, such as charge data, when determining the appropriate payment amount.


To ensure that patients are completely protected, benefits should be assigned to the physician or other providers so that they may pursue payment for services provided directly with the insurer without further involving the patient. This is to ensure that games that have been played by insurers, such as making periodic payments directly to the patient, are not allowed and that the patient is fully kept out of the middle.


Congress should ensure that patients are reasonably able to access the benefits their health plans promised when they signed up for coverage. Insurers must also ensure that their provider directories are accurate and up-to-date so patients can make informed decisions about their care.


Key talking points on surprise billing legislation should include:

  • Establishing benchmark rates that are fair to all stakeholders in the private market; benchmark rates should include actual local charges as determined through an independent claims database.
  • Establishing a fair and independent dispute resolution (IDR) process to resolve disputes about payments from insurers to unaffiliated providers for services rendered out of network to their beneficiaries.
  • Protecting patients from out-of-network billing and preserve patient access to hospital-based care by holding insurers accountable for addressing their own contributions to the problem.


Visit the MSMS Action Center today to email Congress and ask them to support surprise billing legislation that protects the patient and holds insurers accountable.