Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Policy and Regulation News

Senators Propose Limits on Surprise Healthcare Billing

A bipartisan group of Senators are proposing legislation to limit surprise healthcare billing, which can leave consumers with significant medical debts.

Senators aim to solve issues related to surprise provider billing

Source: Thinkstock

By Thomas Beaton

- A bipartisan group of Senators has introduced legislation that aims to end surprise healthcare billing, a practice which can lead to extremely high out-of-pocket costs for consumers.

The Protecting Patients from Surprise Medical Bills Act is intended to address surprise billing and ultimately limit the ability of healthcare providers to charge significantly higher prices for out-of-network services.

Senators Bill Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO) believe that new policy solutions can immediately solve consumers’ frustrations with surprise billing.

“Patients should have the power, even in emergency situations when they are unable to negotiate,” Cassidy said. “Our proposal protects patients in those emergency situations where current law does not, so that they don’t receive a surprise bill that is basically uncapped by anything but a sense of shame.”

If passed, the bill would prohibit providers from charging a patient the difference between what a payer covers and the cost of an out-of-network ED visit. Payers would pay the difference between a provider’s costs and the health plan’s current benefit allowance.

The bill also sets specific rates for how much payers are required to pay if patients use non-emergency services out-of-network within certain regions.

Payers would pay the average amount for out-of-network services based on negotiated rates in a geographic area. State governments can either calculate the average cost and establish baseline amounts or set out-of-network rates at a maximum of 125 percent of average provider costs.

Lawmakers also included a provision that would require providers to disclose when they are referring patients to additional out-of-network services.

Providers would have to notify patients in writing about additional costs, and increased cost sharing, when using out-of-network services. Providers wouldn’t be able to refer patients to out-of-network services without a patient’s written consent, and would be required to provide the option to refer patients to in-network providers instead.

The bill also states that HHS would conduct a feasibility study by 2025 about the impacts of the bill on cost sharing, access to care, healthcare costs, and emergency care use.

Senator Young added that the legislation was designed with input from industry experts that focus on critical first steps to address surprise billing.

“Over the last several months, we have evaluated input from healthcare experts and stakeholders to determine what steps can be taken to lower health care costs for patients,” Young said.

“This evaluation revealed that surprise medical billing is an issue we can address right away to have an immediate impact on health care costs. Surprise medical billing occurs when a patient receives an unexpected medical bill from a doctor that is unknowingly out-of-network. This is just the first of several issues that the bipartisan working group will tackle as a result of our review, and I believe it is the right place to start.”

Legislation that addresses surprise billing may help payers provide more affordable services and address consumers’ negative associations between payers and surprise billing.

A majority of consumers blame payers when they receive a surprise provider bill and say that a lack of communication and little available, and unavailable information about out-of-network billing, lead to their surprise bills.


Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...