Surprise Medical Billing (Balance Billing) Potential Federal Legislation

Posted by Rick Kleehammer on 05/28/2019

Update: Surprise Medical Billing (Balance Billing) Potential Federal Legislation

Many emergency medicine groups are currently out-of-network with major private insurers, and therefore bill patients the difference between their charges and what the insurance company paid (referred to as “balance billing”).

This scenario may cause friction with patients and hospital administrators, especially where the hospital itself is in-network with the payer. However, many emergency medicine groups believe the in-network rates offered by some private insurers are inadequate and leave them no choice but to remain non-par with those payers.

Such bills are often included under the term “surprise medical bills” because patients were treated at an in-network facility, but the provider group itself was out-of-network and balance billed the patient. Some states have already addressed surprise medical bills and pressure has mounted on Congress to take action at the federal level.

This month a flurry of activity on Capitol Hill has produced legislative drafts, hearings, and announcements focused on surprise medical billing. The Senate, House, and Administration have all announced plans to address the situation, including a number of possible approaches. All agree that the patient should be taken out of the process and be responsible for only their in-network deductibles and co-insurance.

Final legislation is likely to contain recommendations from legislative and other stakeholders, which propose various solutions, such as:

  • Set Rates: pay out-of-network providers a median in-network rate
  • Network Matching: require all hospital-based providers be contracted with the same payers as the hospital
  • Bundled Billing: prevent hospital-based providers from submitting claims or billing patients (the facility would provide a single claim, including professional fees; physicians would be reimbursed by the facility)
  • Consent: Require patient notification and consent to balance bill for out-of-network services
  • Arbitration: create arbitration processes for providers and payers disputing the amount of out-of-network reimbursement
  • Databases: create state-based databases to collect claims and payment data for all payers
  • Price Transparency: healthcare providers to furnish expected costs for services to patients in advance of treatment
  • Network Adequacy: requirements that insurers provide adequate networks

Innovative is closely monitoring the situation and will be part of a group visiting with congressional and administration officials in Washington next month regarding healthcare reform in general, and surprise medical billing in particular.

Innovative executives are actively involved in national organizations that help inform and guide policymakers on healthcare issues, including: Healthcare Business Management Association (HBMA), American College of Emergency Physicians (ACEP), Emergency Department Practice Management Association (EDPMA), American College of Osteopathic Emergency Physicians (ACOEP), Workgroup for Electronic Data Interchange (WEDI), and others.


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