Last Updated: Dec 9, 2020
Recent discussions in Washington point to the possibility of congress approving legislation to address the issue of surprise medical bills in the coming days. While there is currently no legislative language to reference, it is important that your member of congress know what key provisions must be included in any potential remedy. Patients often find themselves in the middle of balance billing disputes and must be taken out of the equation, but additionally a commercially reasonable rate for out-of-network services must be included along with a fair process for dispute resolution and arbitration.
Out of Network Services ≠ In-Network Rates
We need you to call and/or email your Congressman NOW and ask them to ensure that any legislation addressing surprise medical bills/out-of-network balance billing contains the following provisions:
- A commercially reasonable rate for out-of-network services such as the “all reasonably necessary costs,” which is the existing payment standard for emergency services in the Commonwealth of Pennsylvania and has been for decades.
- Independent dispute resolution (IDR) as the arbitration process to look at whether the payment is appropriate. This encourages fair physician claims and insurer payments from the beginning.
- Removing the patient from the middle of billing disputes by providing for direct payment to providers from payers.
While there is no legislative language or bill number to reference at this time, there has been on-going discussions that suggest something could occur in Washington in the coming days.
This is a critical issue impacting both patients and providers. Your member of Congress needs to hear from YOU RIGHT NOW on the key provisions that MUST be included to appropriately address this problem.
Find your member of Congress here.
Here are some key points:
- We support efforts to take the patient out of the middle but need to craft a bill that is fair.
- Providers must be able to fairly negotiate contracts.
- Insurers will become more powerful and further increase their control over health care if benchmark rate setting is incorporated over a commercially reasonable standard.
- We support giving insurers the ability to determine the payment rate based on market forces as long as it is combined with an independent dispute resolution mechanism that has specific criteria to look at appropriateness of both the provider claim and the insurer payment.
In tandem, evidence exits showing that the “all reasonably necessary costs” standard and providing for independent dispute resolution have been proven both fair and effective elsewhere. New York state has used a similar process for almost five years and in that time, in-network participation has increased, out-of-network billing has been largely eliminated, more clinicians are in-network, and system has been lauded by both clinicians and insurers for its effectiveness and fairness.