For Shock Medical Payments, It’s the Starting of the Finish


The Biden administration is expected to take its first steps on Thursday to finalize the details of a surprise medical bill ban that Congress passed last winter and President Trump signed. Some experts see politics as the primary health care consumer protection that Washington has had for more than a decade.

Surprising medical bills arise when a doctor or other provider who is not part of a patient’s insurance network is unexpectedly involved in caring for a patient. For example, patients can go to a hospital that accepts their insurance but are treated by emergency doctors or anesthetists who don’t – and then the patients send large bills straight away.

Surprising billing has been widely viewed by academics and lawmakers as one of the most annoying common practices in medicine. Millions of Americans receive these types of bills each year, with one in five emergency room visits resulting in such a fee. The new law effectively prohibits the practice.

“This bill represents the greatest patient protection since Obamacare,” said Adam Buckalew, who served as a Republican employee on the committees that drafted the bill in both the House and Senate. “And it’s solidly non-partisan.” Mr Buckalew, now an advisor, advises a number of health insurers who take care of the details of the regulation.

The ban on surprise medical bills was the rare health policy that received widespread and bipartisan support on Capitol Hill. Legislators have been spurred on by numerous stories of patients facing thousands of dollars in debt for bills they could never have avoided. For example, a Texas man faced a $ 7,924 bill from an off-network oral surgeon performing emergency surgery at a network hospital.

Even so, it took years to pass laws as well-funded interests campaigned heavily against the reforms – including millions of dollars spent on television advertising. Some privately owned medical groups relied on surprising billing as a business model and generally opposed reform efforts by Congress.

Congress passed the surprise billing ban in a December 2020 legislative package calling on hospitals and doctors outside the network, as well as insurers, to negotiate a fair price for medical care rather than billing patients. The law applies to hospitals, doctors, and almost all healthcare providers with the exception of ambulances, which have been exempted from the legislation and are likely to remain a major source of surprise bills.

The passage of the ban sparked further aggressive lobbying on how exactly billing disputes between providers and insurers will be resolved when the law enters into force in 2022, with efforts to steer regulations in a more favorable direction.

“Lobbying is still ongoing,” said Loren Adler, deputy director of the USC-Brookings Schaeffer Health Policy Initiative, whose research on the subject influenced lawmakers.

On Thursday, federal officials are expected to begin completing the implementation details of this legislative plan by posting the first major interpretative ordinance. The law provides a system for calculating a benchmark payment and a way for insurers and healthcare providers to turn to a neutral arbitrator if they think that amount is inappropriate.

The rule expected on Thursday won’t be the last to be released before the end of the year, but it will most likely resolve several contentious issues.

Among the more important and controversial provisions is a detailed definition of the “fair” price that arbitrators should consider as a basis for deciding how much the insurance plan typically owes the hospital or doctor. This will be an important metric because it determines how much patients owe – they are still responsible for paying the off-grid doctor their normal co-payment or deductible – and what reimbursement the provider will charge.

Other sensitive issues addressed in the Thursday Rule include how providers must inform patients that they are not part of their insurance network, as well as the framework for a new federal complaint system. The notification rules in the law represent a new form of transparency – doctors and hospitals must warn patients if their treatment is not covered by insurance.

The complaint system manages submissions from patients who believe their hospital or doctor is sending bills that are illegal under the new law. The law provides $ 500 million in funding for this new system and gives the federal government the power to impose fines of up to $ 10,000 per billing violation.

Some consumer advocates fear providers could continue to bill patients illegally without strict enforcement, and will be on the lookout for rules that will robustly enforce the new safeguards.

Subsequent rounds of regulation will provide more detailed information on how the arbitration process will work and which factors the neutral arbitrator may or may not consider when deciding on the right price for a medical service. Another rule is expected to apply specifically to air ambulances, governed by the new law and prone to generating some of the most expensive surprise medical bills.