Coalition Agrees on Need to Protect Patients From Surprise Medical Bills

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Nine organizations representing health insurance companies, consumers, and businesses announced Monday that they support the concept of federal legislation to protect patients from receiving surprise medical bills.

Nine organizations representing health insurance companies, consumers, and businesses announced Monday that they support the concept of federal legislation to protect patients from receiving surprise medical bills.

The organizations include America’s Health Insurance Plans (AHIP), American Benefits Council, Blue Cross Blue Shield Association, Consumers Union, the ERISA Industry Committee, Families USA, the National Association of Health and of Underwriters, the National Business Group on Health, and the National Retail Federation.

The organization said they agree to 4 guiding principles about this issue, including:

  • Protecting patients from surprise medical bills through federal legislation. Patients should not be penalized in cases where they receive out-of-network care through no fault of their own, the organizations said.
  • Informing patients when care is out of network. Patients need information about what is and is not covered that is specific and timely, and written in plain language.
  • Creating federal policies that restrain costs and ensure quality networks while also protecting patients from surprise bills. Using language from CMS—their “putting patients first” priority—the statement said that federal policies built around a patients-first policy should mean that premiums are not raised unevenly, and network participation is not disincentivized by low rates. Providers should be fairly compensated for their services, the statement said.
  • Using a federal standard when deciding on payments to out-of-network doctors. This is necessary, the organizations said, because the Employee Retirement Income Security Act (ERISA) prohibits all but a few states (which opted to set their own laws) from regulating self-insured health plans. These plans insure about half of all Americans. Any federal standard for payments to out-of-network doctors should apply to self-funded recent health plans, the organizations said.

The statement was released as United Healthcare, which is not a member of AHIP, is engaged in a battle with the country’s largest physician employment group, Envision Healthcare. Bloomberg reported that the contract fight is over prices that Envision’s 25,000 emergency department physicians, anesthesiologists, and other doctors charge. If the contract impasse is not settled by the end of the year, consumers who are insured with UnitedHealthcare could face expensive medical bills after January 1, 2019.

A spokeswoman for AHIP said the statement about guiding principles released Monday is not related to the dispute and noted that UnitedHealthcare is not a member. But the issue ranks high among the public; a September poll from the Kaiser Family Foundation found that unexpected medical bills worried 67% of Americans and that 4 out of 10 had received such a bill in the past year.

A number of legislative bills have been introduced to limit consumer exposure to out-of-network bills. Senator Maggie Hasan and Senator Jeanne Shaheen, both Democrats from New Hampshire, introduced 2 measures this fall.

Hassan introduced S. 3592, the No More Surprise Medical Bills Act of 2018. In emergency situations, out-of-network healthcare providers would not be able to charge patients more than they would have otherwise been required to pay if the bill had come from an in-network provider.

Shaheen’s bill, S. 3591, the Reducing Cost for Out-of-Network Services Act of 2018, would set limits on the amount that out-of-network providers can charge and allows states to pick among 3 options to set the limit: 125% of the Medicare fee-for-service rate, with allowances for rural areas; 80% of the usual and customary rate of the provider’s bill; or the insurers’ in-network rate for the same service. It would also set up a binding arbitration process between insurers and providers.

Another bill, the bipartisan Protecting Patients from Surprise Medical Bills Act (PPSMBA), would regulate 3 areas: emergency services provided by an out-of-network provider in an out-of-network facility, nonemergency services following an emergency service from an out-of-network facility, and nonemergency services performed by an out-of-network provider at an in- network facility.

That bill is sponsored by Senators Bill Cassidy, MD, R-Lousiana; Michael Bennet, D-Colorado; Chuck Grassley, R-Iowa; Tom Carper, D-Delaware; Todd Young, R-Indiana; and Claire McCaskill, D-Missouri.