The College proposed three principles to Congress: hold patients harmless, ensure network adequacy and opt for fair payment with dispute resolution process
August 16, 2019 (ACP) – The American College of Physicians is serving as both an advocate and resource as the U.S. Congress considers how to best address the practice of “surprise billing” in the American medical system.
“Surprise billing” occurs when patients who seek medical care – typically at a hospital – are stuck with huge unexpected expenses even though they believe they have reliable and comprehensive insurance.
According to a 2019 report by the Kaiser Family Foundation, an estimated one in every six hospital visits by patients insured through large employers resulted in a surprise bill in 2017. (Patients older than 65 years were excluded from the analysis.)
Members of Congress from both parties have expressed concern about surprise bills, and legislation is working its way through the House and Senate. Meanwhile, the president issued an executive order in June requiring transparency of health care costs. The executive order calls for expanding access to health care data as well as regulatory steps to address surprise billing.
“ACP is pleased that these legislative proposals hold the patient harmless from surprise medical bills, especially in the emergency room setting, and only make them responsible for the in-network rate,” said Jonni McCrann, ACP's senior manager of legislative affairs.
“However,” she added, “several bills would mandate that in cases where patients receive out-of-network services in an emergency or from out-of-network physicians at an in-network facility, the plan would only be required to pay the physician at the plan-specific median in-network rate. ACP opposes the establishment of a median in-network rate because this approach shields insurers from any responsibility to pay fairly, appropriately and competitively for services and does not ensure network adequacy.”
In letters to the House Energy and Commerce Committee, the Senate Committee on Health, Education, Labor and Pensions, House Committee on Ways and Means, and House Committee on Education and Labor, ACP urged Congress to adopt the following principles.
Hold Patients Harmless: Congress should establish protections for patients to avoid them having to pay for “surprise” bills for out-of-network services when they were unable to obtain estimates for services prior to the receipt of care or were not given the option to select an in-network physician or other clinician. In those situations, ACP supports holding patients responsible only for the in-network rate.
Opt for Fair Payment Instead of Set In-Network Rate: Caps on payment for physicians treating out-of-network patients should be avoided, preferably through the establishment of an independent dispute resolution process that would allow an independent arbitrator to establish an appropriate and fair payment level between the insurer's in-network rate and the clinician's charge.
Ensure Network Adequacy: Congress should examine how network adequacy and the fair payment of services for physicians may contribute to the increase in patients receiving out-of-network care.
ACP continues to encourage stringent quantitative network adequacy criteria; ongoing monitoring and oversight of “provider” networks; transparent “provider” network development criteria; accurate, easily accessible and up-to-date “provider” directories; and requirements that Qualified Health Plans be prohibited from excluding clinicians whose practices include large numbers of patients with expensive medical conditions.
ACP has provided an informational brief on the issue of surprise billing on its state health policy webpage to educate chapters on ACP's position and advocacy activities. “ACP will continue to monitor developments in Congress on this issue and provide constructive feedback to lawmakers as needed,” McCrann said. “And we will continue to make resources available to ACP's chapters to keep them informed and, if appropriate, to engage when needed.”
ACP's information brief “Congress Works to Address Surprise Medical Billing” is available on the ACP website.