Healthcare groups outline 7 policy recommendations for surprise medical bill legislation

Prominent healthcare organizations, including the American College of Radiology (ACR) and American Medical Association (AMA), have asked Congress to consider certain policy recommendations during its push to protect patients from surprise medical bills.  

In a letter addressed to representatives from the House Committee on Ways and Means and Committee on Education and Labor, the organizations said they are committed to “protecting the patients we serve from surprise medical bills and keeping them out of the middle of any billing disputes that might arise between insurers and physicians.”

“As your committees develop a legislative solution to protect patients from surprise medical bills, we urge you to keep in mind the potential for unintended consequences of congressional action to impact patient access to care, particularly in rural and underserved communities,” according to the letter.

These are seven policy recommendations outlined in the letter:

1. Protect patients by limiting their responsibility. “Patients should be protected from surprise medical bills when they unknowingly receive services from out-of-network providers in in-network facilities, and should be out of any payment disputes between physicians and insurers that can arise,” according to the letter. And when disputes do occur, the groups added, patients should “only be responsible for in-network cost-sharing” with no balance billing allowed.

2. Avoid rate-setting. The groups pushed for a payment process for out-of-network care that “maintains a level playing field for future in-network contract negotiations.” A benchmarked rate benefits the insurance providers, according to the groups, while having a negative impact on physicians and patients.

3. Ensure upfront payment from insurers to healthcare providers. “If any guardrail(s) is specified around this upfront payment in legislation, it must be ensured that it will not disincentivize insurers from negotiating fair contracts to bring physicians in-network,” according to the letter.

4. Develop a robust independent dispute resolution (IDR) mechanism. This point has already been at the center of discussions surrounding surprise medical billing. Healthcare groups believe an IDR mechanism pushes providers to set reasonable prices and insurers to provide timely payments.

5. Keep out-of-network care an option with patient consent. “We believe patients should have the opportunity to knowingly receive care from the out-of-network provider of their choice for elective services,” according to the letter. “Providers should be forthcoming with their network status during consultations with the patient, just as carriers should properly inform patients about which physicians are within their network.”

6. Strengthen network adequacy. The groups wrote that “strong oversight and enforcement of network adequacy” is needed on both a state and federal level, pointing out that “narrow network design by insurers” is a key reason for the current situation.

7. Ensure transparency from insurance providers. Patients need to know that the provider directories they search through are updated and correct, the groups explained. Insurance providers, they added, should also “be held responsible for complying with the prudent layperson standard for determining coverage for emergency care.”

Besides the ACR and AMA, eight other organizations signed the letter: the American Association of Neurological Surgeons, American Association of Orthopedic Surgeons, American College of Emergency Physicians, American College of Surgeons, American Society of Anesthesiologists, American Society of Plastic Surgeons, College of American Pathologists and Congress of Neurological Surgeons.