Senate Health Committee Chairman Lamar Alexander (R-Tennessee) and House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-New Jersey) along with Ranking Member Greg Walden (R-Oregon) released a bipartisan and bicameral legislation Sunday that addresses surprise billing. A surprise bill occurs when a patient is unexpectedly billed for an out-of-network provider who is not covered by the patient’s insurance.
Among the numerous provisions, the bill would:
-
prohibit balance billing under certain circumstances. Patients would be required to pay only the in-network cost-sharing amount for out-of-network emergency care (including air ambulance services), for certain ancillary services provided by out-of-network providers at in-network facilities, and for out-of-network care provided at in-network facilities without the patient’s informed consent.
-
require insurers to reimburse providers for all claims subject to the balance billing prohibition at the median in-network negotiated rate for the service in that geographic area where the service was delivered at a minimum.
-
allow both providers and insurers the right to contest claims paid at or above $750 using baseball-style, binding arbitration.
-
require notice and disclosure of balanced bill with at least 72-hour notice to receiving out-of-network care.
-
restrict certain contracting terms between providers and health plans. Specifically, they would enable health plans to unfairly tier providers, steer patients to particular providers, and contract with only certain providers or “cherry-pick” within a hospital system.
-
require providers and health plans to give patients good faith estimates of their expected out-of-pocket costs within two days of a request.
-
set timelines for billing. The bill would require providers to give patients an itemized list of services received not later than 15 calendar days after discharge. In addition, providers would have 20 calendar days after discharge to bill the health plan; health plans would have 20 calendar days to adjudicate the bill; and providers would have no more than 20 days to send the adjudicated bill to the patient. Patients would have no obligation to pay any bills received more than 60 calendar days after receiving care, subject to some extenuating circumstances identified by the Secretary of the Department of Health and Human Services.
