Debate heated up this week on multiple proposals in Congress to squash surprise bills that can expose patients to exorbitant medical charges.

Two proposals in the House moved out of committee this week as lawmakers aim to include a ban in legislation for funding Medicare and Medicaid programs set to expire toward the end of May.

One of the drafts, adopted by the House Ways and Means Committee, includes the preferred fix for hospitals and providers as it relies on using arbitration to fix disputes over out-of-network bills.

A measure from the House Committee on Education and Labor uses a blend of set rates and arbitration. Rates would be set for disputes under a certain threshold, after exceeding that bar, parties can initiate an arbitration process. Providers are vigorously opposed to rate-setting, a method preferred by payers.

A third proposal — backed by the White House — came from both House Energy and Commerce and Senate Health, Education Labor and Pensions committees. It was introduced in December but failed to make it into the year-end spending bill.

On Wednesday, President Donald Trump tweeted his support for a fix to surprise bills as the two bills advanced out of committee. 

Here is a side-by-side comparison of the leading proposals.

  House Energy and Commerce, Senate HELP House Ways and Means House Education and Labor 
Arbitration For services above $750, or $25,000 for air ambulances, payers and providers could elect a baseball-style, binding arbitration process. The arbitrator is required to consider certain information, including training and experience of a provider, market share of both payer and provider and patient acuity. The party that initiated arbitration is barred from bringing the same party to arbitration for the same service for 90 days. There is a two-step process to resolve disputes, which have no minimum dollar figure. First, either party may begin a 30-day negotiation period to exchange information and attempt resolution. Second, either party can initiate a mediation process with an independent third party. The payer and provider present final offers then. For disputes over services that cost more than $750, or $25,000 for air ambulances, payers and providers could enter into independent dispute resolution, an arbitration-type process, to determine a payment for service.
Set rates This proposal requires insurers to pay the median in-network rate in a given region for services under $750. There is no set rate for out-of-network services, but the third-party mediator will “consider the median contracted rate specific to the plan, and for similar providers, services, and geographic areas” during dispute resolution. A benchmark rate would be applied to care under $750. The rate would be set at the median in-network price for a service in a given geographic region. The benchmark rate would apply for air ambulances disputes below $25,000.
Transparency elements Prohibits certain out-of-network providers from sending a balance bill to patients unless the provider gives 72 hours notice of network status before the patient receives out-of-network care and the patient provides consent. Requires providers to publish certain in-network and out-of-network cost information including deductibles on member insurance cards. This bill also requires air ambulances to provide cost and claims data to HHS. Patients will receive a “true and honest cost estimate” before services are rendered that includes cost, what providers will deliver the service and whether those providers are in-network. Requires air ambulance companies to report to HHS cost data and insurers must report claims data for the services.​ Prohibits certain out-of-network providers from sending a balance bill unless a notice is sent 72 hours in advance of the elective out-of-network procedure and the patient signs a consent form. Requires providers and payers to provide a “good faith estimate” of the costs owed for a service within two business days of the request. Payers are required to print the cost-sharing amounts and deductibles on insurance cards for in-network and out-of-network services.
Emergencies Patients are only required to pay the in-network amount for out-of-network emergency care. It also protects patients from certain ancillary services delivered by out-of-network providers at in-network facilities.  Providers will be prohibited from sending a balance bill to patients receiving emergency medical services from a non-participating provider or facility.  Protects patients from a surprise bill in an emergency situation, including air ambulances. Patients would be required to pay the in-network amount for the service when the patient had no option to choose the facility or provider. Patients would only be subject to in-network costs when treated by certain out-of-network specialists without their knowledge.
Latest action Introduced in December and failed to make it into an end-of-year spending package. Passed out of committee Wednesday. Passed out of committee Tuesday.

 





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