House Ways and Means Releases Surprise Billing Proposal

February 2020 ~

On February 7, the U.S. House Ways and Means Committee released its proposed Consumer Protections Against Surprise Medical Bills Act of 2020. If passed, the proposal would ban balance billing for emergency care, care provided by a nonparticipating provider in a participating facility, and in other circumstances of misinformation. The proposal also includes provisions to establish a dispute resolution process for out-of-network reimbursement disagreements.

According to the bill’s summary, the bill will protect patients from surprise medical bills for out-of-network services by prohibiting providers (including facilities) from balance billing patients for surprise services and charging more than the in-network cost-sharing amount.

Patients will receive a true and honest cost estimate” Advance Explanations of Benefits that will provide details regarding which provider(s) will deliver their treatment, costs for services, as well as the network status of the provider. Additionally, if the attending provider changes network status during treatment, the patient would have up to a 90-day period of continued coverage at in-network cost-sharing rates to allow for a transition of care to an in-network provider.

The bill, if passed, would also establish that when a patient receives a surprise bill for out-of-network medical care at an in-network facility or emergency care, the care providers and insurers would be responsible for negotiating payment through a dispute resolution process until the issue is resolved.

As seen in the Committee’s section-by-section summary of the bill, “when health plans and providers are unable to come to an agreement on their own about reimbursement, the Secretary will establish an independent, unbiased process for resolving payment disputes for out-of-network emergency services and for services furnished by nonparticipating providers at a participating facility.

If the provider and health plan cannot agree on a payment amount after a service is provided to a patient, the parties may enter a 30-day open negotiation process with the goal of reducing the information asymmetry to encourage the resolution of disagreements. Both parties are required to share specified information with each other at this stage to facilitate an agreement. The use or potential for use, of this process does not absolve a health plan from any existing requirements to render payment to a provider when a service is provided.

In the case when no resolution has been reached during the open negotiation, either party can initiate a mediated process to resolve the dispute that must end within 30 days. This process is administered by independent entities with no affiliation to providers or payers, either mutually agreed on or randomly assigned. The Secretary shall ensure the selection process is unbiased.

During mediation, the parties will present best and final offers to the mediator, along with other relevant and supporting information. The dispute resolution entity will consider a median contracted rate specific to the type of plan or provider, type of service, and geographic location. Independent entities are prohibited from considering usual and customary charges or billed charges. There is no minimum dollar threshold to bring cases, and the Secretary is permitted to develop a process that would allow batching of similar claims if it would promote efficiency.

The Secretaries will have to periodically publish a publicly accessible report on outcomes from the process and its impact on consumers, payers, and providers. The Secretaries shall also promulgate through rule-making the process for determining the median contracted rate and shall ensure such rates used by health plans are audited.”

In releasing the proposal, House Ways and Means Committee Chairman Richard Neal stated, “Our bipartisan solution to end surprise medical bills will protect Americans from unexpected financial burdens when receiving health care. We are putting patients first, providing unprecedented protection and transparency. Our bipartisan approach differs from other proposals in that we require – for the first time – that patients receive a true and honest bill in advance of scheduled procedures and we create a more balanced negotiation process to encourage all parties to resolve their reimbursement differences before using the streamlined and fair dispute resolution process. We recognize that any solution to this problem touches every part of our nation’s health care system. We want to minimize the burden on patients and keep the dispute resolution process neutral.”

Chairman Neal continued, “Our priority throughout the painstaking process of crafting our legislation has been to get the policy right for patients, and we firmly believe that we have done that. We look forward to working with our Democratic and Republican colleagues in Congress, as well as the Administration, to advance this measure swiftly.”

Source(s): EDPMA News Alert:  House Ways and Means Releases Proposal on Surprise Billing; HealthcareDIVE; Modern Healthcare; Lexology; Health Leaders Media;