Policy & Regulation News

Senators Seek Payer, Provider Data on Surprise Medical Bills

The information will ideally help the senators craft bipartisan legislation combating surprise medical bills.

surprise medical bills

Source: Thinkstock

By Sara Heath

- A group of US senators are calling on healthcare payers and providers to offer more information about surprise medical bills and balance billing. Ideally, this information will help the legislators supplement their bipartisan bill to combat surprise medical bills.

A surprise medical bill is a set of medical charges a patient was not expecting to receive. Surprise bills often occur when a patient receives out-of-network care that she believed would be in-network – treatment from an out-of-network physician in an in-network hospital, for example.

In rarer cases, surprise medical bills occur when an incapacitated patient is taken to an out-of-network emergency department (ED). Patients may also receive a surprise medical bill if the bill is for a larger amount that anticipated.

Recent data suggests that nearly two-thirds of patients have received a medical charge that they determined to be a surprise medical bill.

The US Senate is working to address this issue, which can cause undue stress on patients and open hospitals to patient collections issues. In September 2018, Senators Bill Cassidy, MD (R-LA), Michael Bennet (D-CO), Todd Young (R-IN), Tom Carper (D-DE), Lisa Murkowski (R-AK), and Maggie Hassan (D-NH), proposed a bill that would include patient protections from surprise medical bills.

READ MORE: Industry Groups Call on Protections from Surprise Medical Bills

Now, the legislators are calling on health payers and providers to grant more information about out-of-network care and balance billing to help them supplement their bill.

“As we continue our bipartisan effort to lower health care costs and improve price transparency, we seek more detailed information in addition to what we have received thus far,” the senators wrote.

“Surprise medical billing is a complex problem, and crafting bipartisan, effective legislation to address it will require greater engagement from the private sector. We want to protect patients from costly surprise bills while preventing undue disruption in the health care system. To meet this goal, it is critical that we receive additional data and more complete feedback in order to refine and inform our legislative proposal.”

Specifically, the senators asked for information about Alaska, California, Colorado, Florida, Maryland, New York, and Texas, all of which have balance billing laws.

Questions largely centered on protocol for out-of-network providers, balance billing, and how patient payments compare to Medicare rates.

READ MORE: Bipartisan Proposal to Protect Patients from Surprise Medical Bills

Specific questions for health plans include but are not limited to:

  • How much the payer pays for out-of-network care for different facility types, different plan types (HMO, PPO), and market type. How do these rates compare to Medicare, in-network rates, and provider charges?
  • How much of the plan’s premiums are attributable to the emergency department, radiologists, anesthesiologists, pathologists, ambulance services, and laboratory services?
  • Does the payer have a process for identifying when a provider sends balance bills? Why or why not?
  • What plan does the payer have in place to ensure network adequacy and to encourage physicians to contract with the payer?
  • What role do hospitals play in preventing surprise medical bills?

Questions for providers include but are not limited to:

  • What is the average out-of-network payment providers receive for emergency care? How does this compare to Medicare rates?
  • How do providers explain cost increase trends, despite limited changes in healthcare utilization?
  • How often are balance bills sent to patients who received care from an out-of-network clinician in an in-network facility?
  • What percentage of care provided in the emergency department results in bad debt from patients not following through on their financial responsibility?
  • What are top strategies for encouraging in-network contracting between payers and providers?

The letter also includes other questions pertaining to percentages of out-of-network care delivered and effective state models for out-of-network transparency.

This letter follows proposed bipartisan legislation from this group of senators. The legislation, proposed in September 2018, proposes to enact patient protections against surprise medical billing. Specifically, the legislation would address when patients receive emergency care in an in-network ED from an out-of-network provider. It also considers the non-emergency treatment a patient receives following ED admission.

The bill would require better transparency when patients receive care from an out-of-network provider in an in-network facility. Should the patient receive treatment from this clinician, the patient may only be charged their health payer co-payment.

READ MORE: 67% of Patients Worry About Surprise Medical Bills, Healthcare Costs

The clinician may not charge the patient directly; instead, clinicians must negotiate with healthcare payers, who may either pay the clinician the median charge for in-network care for that service or 125 percent of the average price in that geographic region.

The legislation calls for similar protocol when a patient receives emergency treatment in an out-of-network facility by an out-of-network provider.

The draft also proposes increasing healthcare transparency when a patient receives follow-up care to an emergency situation.

For example, once the initial symptoms of a heart attack have been mitigated, the patient may be in store for other, less urgent treatments. If those treatments are administered by an out-of-network physician, the patient may be liable for a surprise medical bill. The bill would require hospitals to be more transparent in these situations, offering patients the opportunity to receive care from an in-network provider.

“Increasing transparency is one of the most important steps we must take to improve our health care system,” said Senator Bennet, one of the bill’s co-sponors. “Patients deserve to know how much they are paying for health care services and procedures at the point of care. I’ll keep working with my colleagues to find bipartisan solutions like this to lower costs and improve patient care.”


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