WASHINGTON – Today, key House and Senate Committee leaders announced a bipartisan agreement on legislation to protect patients from surprise medical bills and establish a fair framework to resolve payment disputes between health care providers and health insurance companies.
The deal was agreed to by House Ways and Means Committee Republican Leader Kevin Brady (R-TX) and Chairman Richard E. Neal (D-MA), House Energy and Commerce Committee Republican Leader Greg Walden (R-OR) and Chairman Frank Pallone, Jr. (D-NJ), House Education and Labor Committee Republican Leader Virginia Foxx (R-NC) and Chairman Robert C. “Bobby” Scott (D-VA), and Senate Health, Education, Labor, and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA).
“We have reached a bipartisan, bicameral deal in principle to protect patients from surprise medical bills and promote fairness in payment disputes between insurers and providers, without increasing premiums for patients or interfering with strong, state-level solutions already on the books,” the bipartisan, bicameral Committee leaders said. “Under this agreement, the days of patients receiving devastating surprise out-of-network medical bills will be over. Patients should not be penalized with these outrageous bills simply because they were rushed to an out-of-network hospital or unknowingly treated by an out-of-network provider at an in-network facility. This is a win for patients and their families that will improve America’s health care system.
“We are pleased to share this language for stakeholder feedback and are continuing to work together to finalize and attach this important new patient protection to the end-of-year funding package. We’re hopeful this legislation will be signed into law in the coming days so we can give Americans confidence they will no longer receive financially ruinous surprise out-of-network medical bills.”
The bipartisan, bicameral agreement protects patients and establishes a fair payment dispute process including:
- Holds patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts, including deductibles, in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider.
- Prohibits certain out-of-network providers from balance billing patients unless the provider gives the patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care.
- Creates a framework that takes patients out of the middle, and allows health care providers and insurers to resolve payment disputes without involving the patient.
- Under the agreement, insurers will make a payment to the provider that is determined either through negotiation between the parties or an independent dispute resolution (IDR) process. There is no minimum payment threshold to enter IDR, and claims may be batched together to ease administrative burdens.
- If the parties choose to utilize the IDR process, both parties would each submit an offer to the independent arbiter. When choosing between the two offers the arbiter is required to consider the median in-network rate, information related to the training and experience of the provider, the market share of the parties, previous contracting history between the parties, complexity of the services provided, and any other information submitted by the parties.
- Following an IDR process, the party that initiated the dispute may not take the same party to arbitration for the same item or service for 90-days following a determination by the arbitrator. However, all claims that occur during the 90-day period are eligible for IDR after the 90-days.
- Provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers.
- Empowers consumers by providing a true and honest cost estimate that describes which providers will deliver their treatment, the cost of services, and provider network status.
As part of the legislative agreement, the package includes a long-term extension of expiring public health programs, including: Community Health Centers, National Health Service Corps, Teaching Health Centers, and Special Diabetes Programs.
Legislative text is available HERE.
Section-by-section is available HERE.