Senate, House Announce Surprise Billing Deal

December 2019 ~

House and Senate Committee Leaders have announced that the Senate Health, Education, Labor and Pensions (HELP) Committee and the House Energy and Commerce Committee have reached a bipartisan agreement on legislation to address surprise billing including an arbitration process.

According to the announcement, the Lower Health Care Costs Act of 2019, if finalized, would reduce patients’ out-of-pocket (OOP) expenses for health care, end surprise billing of patients, and include a new system for independent dispute resolution often called arbitration.

Key provisions under the bill, include:

  • Protecting Patients Against Out-Of-Network Deductibles in Emergencies
    • Expands the existing patient protections for emergency services that apply to the emergency department of a hospital included in the Public Health Service Act also apply to freestanding emergency.
  • Protection Against Surprise Bills
    • Patients are held harmless from surprise medical bills.
  • Benchmark for Payment
    • For surprise bills, health plans would pay providers the local median contracted commercial amount under that plan or coverage that insurers have negotiated with other providers and agreed upon in that geographic area. Payments must be made in a timely fashion.
  • Increasing Transparency by Removing Gag Clauses on Price and Quality Information
    • Bans gag clauses in contracts between providers and health plans that prevent enrollees, plan sponsors, or referring providers from seeing cost and quality data on providers.
  • Banning Anticompetitive Terms in Facility And Insurance Contracts That Limit Access to Higher Quality, Lower Cost Care
    • Prevents “anti-tiering” and “anti-steering” clauses in contracts between providers and health plans that restrict the plan from directing or incentivizing patients to use specific providers and facilities with higher quality and lower prices.
  • Designation of a Nongovernmental, Nonprofit Transparency Organization to Lower Americans’ Health Care Costs
    • Designates a nongovernmental, nonprofit entity to improve the transparency of health care costs and directs HHS to contract with said nonprofit entity within one year of the passage of the legislation.
  • Protecting Patients and Improving the Accuracy of Provider Directory Information
    • Network Status of Providers. Requires health plans to have up-to-date directories of their in-network providers, which shall be available to patients online, through oral confirmation kept in an enrollees file for a minimum of 2 years and provided in writing within 1 business day of a telephone inquiry. Print directories should include an accurate as of date disclaimer.
  • Timely Bills for Patients
    • Requires health care facilities and providers to give patients a list of services received upon discharge or at the end of the visit or by postal or electronic mail as soon as practicable and not later than 5 calendar days after discharge or date of visit.
    • Requires all adjudicated bills to be furnished to a patient within 45 days. If bills are received more than 45 days after receiving care, the patient is not obligated to pay.
    • Requires providers and facilities to give patients at least 35 days after postmark date to pay bills upon receipt.
    • Provides for civil monetary penalties of up to $10,000 a day for facilities that fail provide a list of services 10 times.
    • Effective date is 6 months after enactment.
  • Expanding Capacity for Health Outcomes
    • Authorizes the provision of technical assistance and grants to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity building models to increase access to specialized health care services in medically underserved areas and for medically underserved populations.
  • Requirement to Provide Health Claims, Network, and Cost Information
    • Requires commercial health insurers to make information available to patients through application programming interfaces, including: health insurance claims data, provider encounter data and payment data; in-network practitioners; and expected out-of-pocket costs. Data to be available to an enrollee or former enrollees, the enrollee’s providers or any third-party applications or services authorized by the enrollee.

The legislation also includes provisions to increase transparency and competition in the prescription drug market, five years of funding for Community Health Centers for five years, increasing the purchasing age of tobacco from 18 to 21, and a provision to allow air ambulance carriers to appeal bills that meet a threshold of $25,000 to an outside arbitrator.

The bill’s sponsors, Senate health committee Chair Lamar Alexander, House Energy & Commerce Chairman Frank Pallone, and Energy & Commerce’s Greg Walden, predict the surprise billing fix would save the government nearly $20 billion. The committees hope to attach the legislation to a bill that extends federal funding beyond the current December 20th funding deadline.

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Source(s): House Committee on Energy and Commerce; Modern Healthcare; Advisory Board; American Hospital Association; HBMA Government Relations, December 11, 2019;