Bipartisan Group of Senators Drafts Legislation to End Surprise Medical Bills

As instances of patients receiving surprise medical bills continue to make headlines, a bipartisan group of senators have unveiled a draft legislation to protect patients from these bills.

Senators Bill Cassidy, MD, R-Louisiana; Michael Bennet, D-Colorado; Chuck Grassley, R-Iowa; Tom Carper, D-Delaware; Todd Young, R-Indiana; and Clair McCaskill, D-Montana, have released the Protecting Patients from Surprise Medical Bills Act, with the intent of spearheading conversations in Congress about how to prevent the utilization of balanced billing to charge patients for treatment and services from an out-of-network provider in an in-network facility.

To read more on balance billing, click here.

Currently, the federal law does not prohibit balance billing in self-funded health plans. A recent analysis found that nearly 18% of inpatient admissions and 7.7% of outpatient service days include a claim from an out-of-network provider, often coming as a surprise to patients when they receive a medical bill from an out-of-network provider after their insurance plan has paid the contracted amount with a provider.“Over the last several months, we have evaluated input from healthcare experts and stakeholders to determine what steps can be taken to lower healthcare costs for patients,” Young said in a statement. “This evaluation revealed that surprise medical billing is an issue we can address right away to have an immediate impact on healthcare costs.”

The draft bill takes into account 3 different situations, 1 of which is emergency services provided by an out-of-network provider in an out-of-network facility. According to the senators, under the bill, patients would only pay the cost-sharing amount indicated by their health plan.

The same would be ensured for nonemergency services provided by an out-of-network provider at an in-network facility. The senators say the draft bill would bar a health plan or out-of-network provider from billing a patient more than their in-network cost-sharing.

The excess amounts in each scenario would instead be paid by the health plan in accordance with an applicable state law, an amount based on the greater of the median in-network amount negotiated by health plans, or 125% of the average allowed amount for the service provided by a provider in the same or similar specialty and provided in the same geographical area.

If a patient receives an emergency service from an out-of-network provider and then receives additional services after being released, the facility would have to notify the patient that he or she may have higher cost-sharing than if the service was received in-network. The patient would be given the option to transfer to an in-network facility and would be required to sign a written acknowledgment of that notification.

“Increasing transparency is one of the most important steps we must take to improve our health system,” said Bennet. “Patients deserve to know how much they are paying for health services and procedures at the point of care.”