A Bipartisan Proposal
The focus of this bill is to protect health consumers from receiving surprise medical bills. Approximately 57% of Americanshave received a surprise medical bill for services that were thought to be “in-network” as assigned by the patient’s insurer but were not covered by health plans. F2C believes that Congressmen Ruiz and Roe’s proposal, H.R. 3502, is the best solution to this complex problem.
A bill proposed by Congressmen Dr. Raul Ruiz (D-CA) and Dr. Phil Roe (R-TN) and referred to the U.S. House Committees of Energy and Commerce, Ways and Means, Oversight and Reform, and Education and Labor.
The focus of this bill is to protect health consumers from receiving surprise medical bills. To evaluate the factors surrounding surprise medical or “balance” bills, it is necessary to provide some context.
Traditionally, three players are usually involved in patient care: the patient, the patient’s insurance provider, and the patient’s doctor. Sometimes, a fourth party is involved: the staffing company that employs the physicians and bills on behalf of the physician’s services.
Approximately 57% of Americans have received a surprise medical bill. The major source of these bills is certain services that were thought to be “in-network” as assigned by the patient’s insurer but were not covered by health plans. These balances of services not paid by the patient’s insurer were revealed to patients upon receiving a “surprise” bill from their physician or health professional.
This commonly – but not always – occurs when patients are taken to the emergency department at a hospital. Patients cannot be expected to know their insurance network arrangements during an emergent situation. Yet, through no fault of their own, they receive a large bill for services rendered.
A similar situation occurs when a patient receives services at a hospital. While the hospital may be listed as “in-network” under the patient’s insurance plan, frequently utilized physicians, labs, or radiology services may not be contracted with the patient’s insurer. When insurers and providers cannot reach a contractual agreement on payment, physicians fall outside the health plan’s network until terms can be brokered by both parties.
To date, no laws have been established to require insurers or their hospital partners to make network arrangements transparent to the patient. One prudent solution is to require hospitals to advertise all regularly used out-of-network services, for example, regularly used anesthesia, radiology, or lab services. The same level of transparency should be expected from a patient’s health insurance provider.
Thus far, two competing policies have prevailed in Congress as a proposed fix to this problem:
(1) Government-assigned market-based payment rates for healthcare providers, known as benchmarking, rate-setting, or price controls.
(2) Independent Dispute Resolution (IDR): An independent arbiter is assigned the task of coming to a binding rate agreement for disputed claims between the insurer and the physician or other healthcare professional.
Free2Care (F2C) is strongly opposed to any legislative measure that uses any modality that would tie physicians to in-network rates as set by insurers.
The devastating and unintended consequences of rate-setting for physicians are below.
Physicians will decline to work within such a system.
“California’s surprise medical billing law has created unintended consequences that increase healthcare costs and reduce quality… Price controls have led to fewer doctors on call in emergency rooms, and independent doctor practices consolidating into bigger hospitals. When the government puts its thumb on the scale, it’s ultimately patients that are hurt the most,” said Dr. Wayne Winegarden, senior fellow and director of the Center for Medical Economics and Innovation at the San Francisco-based Pacific Research Institute, in his recent brief, “The Menace of Medical Rate Setting: The Case of California’s AB 72”.
• Healthcare consolidation will occur, thus increasing healthcare prices.
• Quality of care will suffer
F2C believes that Congressmen Ruiz and Roe’s proposal, H.R. 3502, is the best solution to this complex problem. The proposal carries the most bipartisan support and provides a sensible alternative to benchmarking.
H.R. 3502 supports an independent dispute resolution (IDR) process, similar to those already enacted by state legislatures in two of the largest and politically opposite states: Texas and New York. The bill currently has 110 Republican and Democratic co-sponsors, making it the Congressional surprise medical bill proposal with the largest number of bipartisan supporters, by far.
F2C fully supports removing the patient from the dispute process.
F2C fully supports provisions that lessen the burden of cost-sharing on patients, especially during emergency visits to hospitals. We do not believe in adding insult to injury with large surprise medical bills. A medical emergency should fall within the category of the prudent layperson standard.
F2C strongly supports batching of claims to relieve the burden of resubmitting multiple claims with the same CPT codes for the same services rendered by physicians or other health professionals. Resubmitting claims along with potential fees associated with each submittal would be a deterrent to the submission of claims.
F2C strongly approves of the IDR process to be the most fair and equitable in resolving payments between insurers and physicians, as no such industry standard currently exists. F2C also supports quality standards of neutrality and oversight of the IDR process, as maintained by an oversight agency. Each arbiter’s record should be subject to audit with the regulatory consequences of any proven bias. H.R. 3502 is the only current Congressional proposal for IDR that allows both sides to present their best cases. Other Congressional proposals that would prevent providers from presenting data that would be favorable to their case are fundamentally unfair and not consistent with a functional private healthcare marketplace.
F2C strongly supports legislation that protects patients from the undue burden of receiving unwarranted medical bills.
F2C supports any and all measures that advocate for greater transparency in healthcare. Patients, as consumers, should be knowledgeable about the services provided to them. Both the insurance industry and hospitals must make reforms to provide more clarity to patients about what is and is not covered by the services they receive.
F2C supports any and all measures, including oversight, that keeps the overall cost of healthcare down. Analysis and review of this data will lower the cost of medical care by not only stabilizing it at its current levels or slowing its rate of increase, but also driving it down. This requires identifying, exposing, and eliminating the layers of waste, redundancy, fraud, corruption, and profiteering inherent in those layers.
Additionally, physicians are often not aware of charges billed under their name. Congress should assure, through the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act and other legislation, the due process rights of physicians who ask for transparency in reporting of charges under their names. By doing so, Congress will help physicians ensure that no abuse or fraud is being committed under their name by a third-party billing service.
F2C fully supports HR 3502 that proposes a principled solution to a complex healthcare problem tainted with profit-driven motives.
The bill’s provisions offer the most bipartisan, fair, and equitable solution while closely monitoring their impact on patients and the healthcare market.
No patient should have to pay expensive medical bills for services thought to be covered by their insurance provider, especially during medical emergencies.
Patients should not be accountable for payment of such services when they are not involved in contract negotiations between any of the parties involved.
Bringing more transparency to the opaque healthcare market will benefit both patients and their physicians.
Congress should act now to pass H.R. 3502