Bill on Surprise Medical Billing Moves Forward to Full House Vote

February 12, 2020 - A bipartisan vote in the House Committee on Education and Labor advanced the Ban Surprise Billing Act on February 11, which aims to reduce surprise billing and increase healthcare transparency.

The agreement was a bipartisan effort from the beginning, introduced by Democrat and House Committee chairman Bobby Scott (D-VA) and ranking Republican Virginia Foxx (R-NC).

“Surprise medical billing is a troubling and all-too-common product of our complex health care system. The status quo is unacceptable. Patients are getting hit with astronomical bills and both payers and providers are facing an uncertain future,” said Chairman Scott. “The Ban Surprise Billing Act is a bipartisan solution that protects patients from unexpected, often significant out-of-pocket costs while being fair to both providers and payers.”

“The fear of an unexpected medical bill can be paralyzing, and we as elected Representatives cannot sit idly by as American families forgo care they need for fear that they’ll end up responsible for an unexpected, unaffordable surprise medical bill,” Representative Foxx agreed. “Workers and families deserve certainty about their health care coverage, and by taking action today and advancing the Ban Surprise Billing Act, we move one step closer to giving patients financial confidence.”

The bill applies to both Americans with employer-sponsored health plans and those enrolled in the individual health insurance market.

The Ban Surprise Billing Act specifically:

• Limits patients’ cost-sharing to the in-network rates, even for out-of-network treatments
• Categorizes any out-of-network charges toward the in-network deductibles or out-of-pocket healthcare spending maximums
• Addresses air and ground ambulance billing
• Creates two options for settling payer-provider payment disputes 
• Introduces coverage and price transparency reforms

Since the potential for surprise billing can increase when members find themselves caught in the middle of a payer-provider payment dispute, policymakers have been toying with different solutions to resolving payer-provider conflicts in a timely, low-risk fashion.

Lawmakers have specifically been looking into third-party arbitration and rate-setting as solutions.

The Ban Surprise Billing Act settles payer-provider payment disputes based on the disputed amount. If the amount is $750 or less—or $25,000 if an air ambulance bill—then payment will be allocated based on the median in-network rate market-based benchmark for the service in that area. If the amount is $751 or more—or over $25,000 for air ambulance bills—then the parties can settle on a fair payment using an independent dispute resolution.

The efforts at increasing coverage transparency range from mandating that payers offer updated provider directories to giving consumers access to information about cost-sharing, in- and out-of-network deductibles, and out-of-pocket limits.

The bill is one of three proposals percolating in House committees as policymakers fight against the gridlock to come up with a solution for surprise billing. The other two bills came from the Ways and Means Committee and the Energy and Commerce's Lower Health Care Costs Act of 2019 released in December 2019.

The Ban Surprise Billing Act does not address uninsurance, as the Ways and Means Committee bill does. The Ways and Means Committee bill prefers to keep the federal government out of payment disputes but also provides two methods of resolution, either through a 30-day open negotiation process or an independent, third-party mediation governed by the HHS Secretary’s rules.

The Ways and Means Committee bill is less structured on federal intervention into the payment dispute process in that it does not assign a dispute resolution route based on dollar amount.

Both bills require plans to provide patients with an estimate of their treatment costs and provider network status, but the Ways and Means Committee bill does not address cost-sharing limits.

The Lower Health Care Costs Act of 2019 is much more expansive than either of the other bills.

A product of efforts in both the Senate Health, Education, Labor and Pensions (HELP) Committee and the House Energy and Commerce Committee, the Act covers not just surprise billing, but also prescription drug pricing, Medicare benefits, and the opioid crisis. It addresses surprise billing in Medicare Part D prescription bills by allowing HHS to negotiate drug prices based on international standards.

The number of proposals to surprise billing are a symptom of the ever-increasing urgency for a solution.