Surprise Billing

What’s new?

  • On July 17, 2018 the U.S. House Energy and Commerce Committee advanced, by a voice vote, a substitute amendment to the Community Health Investment, Modernization and Excellence Act of 2019 (HR2328) that added language from the No Surprises Act and directed HHS to establish an independent dispute resolution process.
  • On July 11, 2019 the U.S. House Energy and Commerce Health Subcommittee passed the No Surprises Act (HR 3630). A full committee vote is expected yet in July.
  • HR 3630 would limit unexpected medical bills for patients and set a benchmark rate for payment to providers for certain out-of-network and emergency services.  The benchmark rate would be based on the 2019 median in-network rate for a geographic area, with an index for increase each year.
  • Congress has held multiple hearings on the topic of surprise bills and several pieces of legislation had been drafted in the 116th Congress.
  • On February 20, 2019 The American Hospital Association and The Catholic Health Association along with other provider associations authored a letter committing to Congress that all providers are committed to protecting patients from “surprise bills”.

What is the issue?

  • Reports of patients receiving unexpected, large healthcare bills as a result of hospital stays has generated concern from lawmakers.
  • AARP estimates that one in seven patients will receive a “surprise bill” as a result of a hospital stay.
  • Health insurance and health care billing are complex, and it can be difficult for patients to understand their coverage and obligations.
  • A surprise bill may occur when a patient receives care from an out of network provider or when their health plan fails to pay for covered services. The three most typical scenarios are when:
    • A patient accesses emergency services outside of their insurance network, including from providers while they are away from home
    • A patient receives care from an out of network physician providing services in an in network hospital
    • A health plan denies coverage for emergency services saying they were unnecessary

Why does it matter?

  • Although insurers are in the best position to help patients understand what is considered in network or out of network, everyone providing health care services has a role to play in helping consumers navigate the complicated health care delivery system.
  • Setting a government-mandated rate, which would become a default rate for additional services, could threaten already limited hospital resources and create a disincentive for health plans to establish adequate coverage networks.  This could disproportionately harm patients and hospitals in rural and underserved communities.
  • Patients should have certainty regarding their cost-sharing obligations, which should be based on an in-network amount, and should be assured of access and coverage for emergency care.
  • Patients should not be used as the crosswalk between insurers and healthcare providers. Surprise bills are a direct result of a lack of negotiated contract between the patient’s insurer and the hospital and/or physicians that provided their care.

What is the AMITA Health perspective?

  • AMITA Health believes that all patients, regardless of ability to pay, have a right to high quality, efficient healthcare. Patients through their insurance provider should have access to a comprehensive network of providers, including in-network physicians and specialists at in-network facilities.
  • Families should be protected from financial burdens of unexpected medical bills. Surprise bills are a direct result of a lack of negotiated contracts between insurers and providers.  Patients should be taken out of the middle of standard negotiations when they have not had the opportunity to choose who provides their care.

External Resources

Information from third-party organizations that can be resources for you to continue to learn about the issues at hand.

IHA Surprise Billing Issue Brief

Illinois Health and Hospital Association issue brief on surprise billing.

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Stop Surprise Medical Bills Summary

Summary of bipartisan draft legislation to address surprise medical bills in the U.S. Senate entitled Stop Surprise Medical Bills

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No Surprises Act Discussion Draft

Bipartisan discussion draft of legislation to address surprise billing in the U.S. House of Representatives entitled the No Surprises Act.

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Featured News

Featured news includes articles and tweets from multiple viewpoints and is designed to keep you abreast of the current debate around issues that are important to AMITA Health. This information should not be construed as our point of view.

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