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(Washington, D.C.) – Congressman Larry Bucshon, M.D. (IN-08) released an outline of the bipartisan Protecting People from Surprise Medical Bills Act, forthcoming legislation that will protect patients from unfair and expensive surprise medical bills. The finalized legislation is expected to be introduced in the coming weeks.

“As a physician, I believe it is important that patients are not financially burdened with surprise medical bills for unanticipated out-of-network care,” said Dr. Bucshon. “Instead of picking winners and losers, I support this bipartisan proposal that offers an independent dispute resolution process that is mediated by an arbiter. Access to life saving care is critical for all Americans and it should not come with lifelong penalties.”

Background

Surprise billing – also known as balanced billing – impacts hard-working families across the nation. Currently, patients with private insurance expect that visits to in-network hospitals for medically necessary care will be covered by their insurance. However, patients sometimes receive surprise bills for thousands of dollars from the emergency department or out-of-network providers based at in-network hospitals.

These surprise bills result from disputes between providers and insurance companies. When insurers and providers cannot agree on the cost of care, patients are often on the hook for tens of thousands of dollars in unexpected bills. In 29 states and the District of Columbia, there are no legal protections designed to protect patients from surprise bills. 

Under the Protecting People from Surprise Medical Bills Act, the practice of balance billing would be banned. Patients would be left out of the middle and are not required to play any part in resolving payment disputes. The legislation sets forward the most robust patient protections possible, ensuring families struggling to get by are not bankrupted by surprise medical bills.

The Protecting People from Surprise Medical Bills Act takes a proven approach to protecting patients from surprise bills by adopting an arbitration model. Under this model – similar to the one adopted by New York State in 2015 – if providers and insurers cannot agree on a payment rate, they can engage in an independent dispute resolution process (IDR). Under IDR, insurers and out-of-network providers each identify a cost for the patient’s care, and a neutral arbiter chooses the fairer price. This model creates an incentive for both parties to choose reasonable numbers to cover the cost of treatment. According to a 2018 study, out-of-network bills in New York declined 34 percent just three years after the state passed arbitration legislation.

The Protecting People from Surprise Medical Bills Act will make the following reforms:

• Ban the practice of billing patients for unanticipated out-of-network care;
• Implement a ‘baseball-style’ arbitration model that identifies a reasonable payment rate when insurers and providers cannot agree on the cost of care;
• Improve transparency by requiring health plans to clearly identify in-network providers and patients’ deductibles.

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