Fresh on the heels of a final transparency rule, a bipartisan, bicameral committee of the chairmen and ranking members from each of the following committees have proposed legislation to establish a surprise billing framework:

  • House Ways and Means Committee
  • House Energy and Commerce Committee
  • House Education and Labor Committee
  • Senate Health, Education, Labor, and Pensions (HELP) Committee

For emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider for some of the services, it holds the patient harmless so they are only responsible for in-network cost-sharing.  For someone seeking care in-network, it would require certain out-of-network providers that will be involved in such care to “give the patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services” and to get the patient’s consent before being allowed to balance bill above the in-network allowed charges.

The rest of the framework involves a combination of two competing ideas deliberated in recent months by utilizing an arbitration system without the involvement of the patient, but requiring the arbiter “to consider the median in-network rate, information related to the training and experience of the provider, the market share of the parties, previous contracting history between the parties,” and other relevant facts and circumstances.

IMA will continue to monitor progress on this legislative solution to see if the US House and Senate can come to enough agreement on the proposal to pass it into law.  These committee leaders are hopeful it will be part of the year-end spending package.

This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.