Physician-Lawmakers Shape Congress' 'Surprise-Billing' Fix

Kerry Dooley Young

December 09, 2019

A Republican heart surgeon and a Democratic emergency room physician seem to have scored at least a partial win in their bid for a federal law backing arbitration for disputed out-of-network medical bills.

A House-Senate compromise package unveiled today calls for using benchmark rates to settle disputes about "surprise billing," or cases where consumers with insurance face high costs due to out-of-network services. The benchmark model has been an unpopular premise for many physician organizations.

But the final compromise measure also includes a feature — arbitration — that has been championed by a House odd couple, Reps. Larry Bucshon, MD, R-Ind., a cardiologist, and Raul Ruiz, MD, D-Calif., an emergency medicine physician.

The two lawmakers succeeded in July in substantially altering a House Energy and Commerce Committee legislative proposal. The original plan was similar to a Senate Health, Education, Labor and Pensions (HELP) Committee bill, in that it called for use of benchmarks to settle disputes.

A successful amendment from Ruiz and Bucshon to the House bill added a provision calling for use of independent dispute resolution for out-of-network claims exceeding $1250.

In the House-Senate compromise announced today, clinicians or insurers may elect to go to independent dispute resolution, which is a form of binding arbitration, in cases where the median in-network rate payment rises to more than $750.

"If a bill goes to arbitration, the arbitrator is required to consider information brought by the parties related to the training, education, and experience of the provider, the market share of the parties, and other extenuating factors such as patient acuity and the complexity of furnishing the item or service," the HELP Committee said today in a summary of the new legislative proposal.

The proposal would hold consumers harmless from surprise bills, leaving these disputes for insurers to have with physicians and hospitals, the committee said.

Savings Expected

A press release from the HELP and Energy and Commerce committees said the surprise billing measure would provide nearly $20 billion in savings. The savings could be used to fund other federal programs, such as a popular one for community health centers.

The potential for this offset will make the surprise legislation more attractive to leaders of Congress who now face a challenge to find money to continue several health programs.

The White House issued a statement today praising what it called bipartisan efforts to "move toward ending an unfair practice that causes confusion and concern for millions of Americans." The statement said the White House expects Congress to pass this bill this month and send it to President Donald J. Trump for his signature.

"This compromise reflects the input of doctors and hospitals and is the result of months of delicate work to reach a deal among congressional members and the White House that protects patients," the statement said.

There has been strong political pressure on lawmakers to address surprise billing, as noted by Rep. Greg Walden of Oregon, the ranking Republican on the House Energy and Commerce Committee. Although most medical care is covered by consumers' insurance plans, stories of out-of-network bills topping $100,000 for emergency care have rattled many people's faith in their insurers.

"To put it plainly: Americans are sick and tired of being ripped off by surprise medical bills, and they want Congress to act," Walden said in a statement. "This announcement brings us one step closer to answering that call for action with bipartisan legislation to prohibit surprise medical bills and take the patient out of the middle."

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