Over the last few weeks, several different federal health care price transparency and surprise billing proposals have been unveiled by President Trump and U.S. House and Senate members. While the numerous proposals vary in some regards, they also share many similarities.
A common theme between the proposals is an idea that balance billing should not be allowed in situations where patients did not reasonably choose their setting of care. In other words, balance billing would not be allowed in settings of emergency care or care that patients would expect to be in-network (such as situations where providers contract with and work out of hospitals, but are not in the same network as providers directly employed by the hospital). Another theme common to the proposals is the idea that patients should receive information on out-of-network providers and costs associated with seeing them prior to receiving care.
Where the proposals diverge is determining how to resolve reimbursement disputes between payers and providers. Two proposals introduced in the Senate would use an independent arbitration process combined with median contracted rates to determine how payments are awarded. Legislation introduced by Congressmen Pallone and Walden of the House Energy and Commerce Health Subcommittee would use median contracted rates as determined by the Secretary of Health and Human Services, but would not utilize an arbitration process. Furthermore, legislation introduced by Senator Lamar Alexander and Patty Murray of the Senate Health Education Labor and Pensions (HELP) Committee would require facilities to guarantee that all their practitioners are in-network. Any providers who remain out-of-network would be prohibited from sending a balance bill to patients.
As of now, all proposals would apply only to self-insured plans that are covered under the federal Employee Retirement Income Security Act (ERISA), and usually offered through large employers. This means that health insurance plans offered in the individual, small, or large group markets would not have these regulations unless the state applies such regulations separately through state law. Initial indications are that House and Senate leaders expect to move these proposals through Congress in the summer months.
Surprise billing and transparency were key topics WHA discussed with Wisconsin lawmakers last April in Washington, D.C. While we have been supportive of Congress’ efforts to improve transparency and reduce the incidences of surprise billing, one area of concern is the unintended consequences that arbitration and government-set rates could have in eroding health networks and favoring insurers at the expense of provider-negotiated rates. WHA is reconvening its Transparency Taskforce in June to further analyze these topics and will continue to follow and actively engage in these issues at the federal level.
Contact WHA Vice President of Public Policy Lisa Ellinger
or WHA Director of Federal and State Relations Jon Hoelter
with any questions.