A long-discussed surprise medical billing fix will be part of the congressional budget deal that includes $900 billion in new COVID-19 relief.
“This is terrific news,” said Kim Buckley, vice president of client services for DirectPath. “Previously, there was a patchwork of 31 state-based programs that had attempted to address this issue, with some states taking a more comprehensive approach than others. And these programs only affected fully insured plans in that state and could not address air ambulances, a major source of surprise bills. The new federal legislation will apply a consistent approach to all plans, both self- and fully insured, and extend to those states who have not yet offered consumer protections against surprise bills.”
Though key congressional committees had agreed more than a week ago on a plan for protecting insured patients from large medical bills when they unwittingly receive out-of-network care, it had been unclear whether it would be part of must-pass government funding legislation, ”Politico” reported. The final decision came down to Senate Majority Leader Mitch McConnell, who had been silent on the deal.
The White House already has endorsed the plan nearly two years after President Donald Trump first called on Congress to fix an issue that has drawn bipartisan concern. But those efforts were nearly derailed by opposition from well-funded groups and congressional turf battles. While the health care industry agreed that patients should be held harmless in emergency situations, hospital and physician groups and insurers fought vigorously over who would pick up the tab. The compromise deal congressional committees struck earlier this month was considered largely a win for hospitals and doctors, and tweaks made in the final legislation are even friendlier to providers.
The previously announced deal called for health insurers and providers to negotiate most billing disputes or bring their complaints to a mediator. But in one key change, the final version of the bill would forbid arbiters from taking into account Medicare and Medicaid rates, which typically are much lower than what commercial coverage pays. That is a loss for insurers, employers who fund a major chunk of private coverage, and patient advocates who thought including those public rates as a barometer could help curb health-care prices. As a guardrail, the measure also bars arbiters from considering providers’ billed charges, which usually are well out of line with what insurers or patients end up paying.
However, in a win for health insurers, lawmakers appear to have watered down a measure that would have required them to disclose detailed information to employers about their drug costs and rebates through their contracts with pharmacy benefit managers, whose business practices have come under scrutiny in recent years for their role in high drug costs. Instead, the legislation calls for insurers to submit more general information on medical costs and prescription drug spending to relevant federal agencies, which would feed into a government report on drug pricing trends.
“It remains to be seen how well the arbitration system will work,” Buckley said, “but this is an important step in the right direction for protecting consumers, including those who did all the right things to ensure their care was in-network but received surprise and balance bills through no fault of their own.”