Bipartisan Agreement Reached on 'Surprise Billing' Legislation

Compromise takes both default price and arbitration approach
Robert Calandra

Legislation that would place limits on “surprise” medical bills for patients treated out of network, often in emergency departments,  is a step closer to reality.  


ED care results in surprise bills

Republican and Democratic House and Senate lawmakers have reached a compromise agreement, according to an announcement this week by Sen. Lamar Alexander, the Republican from Tennessee and chair of the Senate Health Committee, and Rep. Frank Pallone, a Democrat from New Jersey, who chairs of the House Energy and Commerce Committee.

While the proposed bill still needs backing by congressional leadership, the White House has endorsed it, the Wall Street Journal reported.

Dylan Scott at Vox explained that the bill is a compromise between two different ways of resolving unexpected out-of-network bills One approach sets a default, or benchmark, payment rate that is based on in-network rates. The other uses an arbitration process that weighs input from providers and insurers.

According to Scott, payers (insurers and employers) and patient groups have pushed for the default system because they believe it will keep payments lower. Providers (doctor and hospital groups) have pushed for  arbitration.

In Scott’s telling, the bipartisan legislation split the difference. If it does, indeed, become law, out-of-network bills under $750 would be paid at a default price based on in-network charges. Bills over that amount could be brought to arbitration.

Healthcare Dive called the Sen. Patty Murray of Washington, the top Democrat on the Senate health committee, “notably absent” from the backers of the legislation. An aide to the senator indicated that she supports the overall agreement but wants changes made.

Healthcare Dive also reported that the American Hospitals Association opposes the draft and characterized it as especially damaging to rural hospitals.

The New York Times  described all the lobbying that the bill had fomented:

“Behind the scenes, lobbyists for doctors, hospitals, air ambulances, insurers and large employer groups have been making the rounds on Capitol Hill. The bonanza for lobbyists and media consultants demonstrates the deep pockets of the health care industry, and the intense interest it takes in even relatively small policy changes.”