Federal Lawmakers and Stakeholders Aligned in Focusing on Protecting Patients from Surprise Balance Bills > Hospital Association of Pennsylvania


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Federal Lawmakers and Stakeholders Aligned in Focusing on Protecting Patients from Surprise Balance Bills

April 03, 2019

Broad consensus continues to emerge regarding the need to pursue policy that will protect patients from surprise balance billing.

In a hearing before the U.S. House Education and Labor Committee—“Examining Surprise Billing:  Protecting Patients from Financial Pain”— federal lawmakers from both parties reiterated their strong intent to reach policy consensus to ensure patients are not confronted with unexpected, surprise bills resulting from out-of-network care. 

Surprise bills may occur when patients receive a bill for care that they thought was covered by health insurance or that stems from out-of-network care. 

During the hearing, lawmakers pressed for federal policy solutions that will, first and foremost, hold patients harmless. Testimony by policy experts, academic researchers, and consumer advocates offered policy suggestions, but demonstrated the difficulty of crafting a comprehensive solution that provides for appropriate payment for needed medical care.

The American Hospital Association (AHA) submitted a statement for the record reiterating the association’s Surprise Balance Billing principles set forth in February.

The AHA has pressed for solutions that would “take patients out of the middle” of standard negotiations between insurers and providers. The association also has emphasized the importance of ensuring that providers are able to negotiate appropriate payment rates with health plans. The AHA urged the committee to reject legislative proposals that specify a national reimbursement rate for out-of-network services. The AHA cautions that this approach would "create a disincentive for insurers to maintain adequate provider networks. It is imperative that plans and providers are able to develop networks that meet consumers’ needs.” 

Additionally, the AHA and two other provider groups, the American Medical Association and the Federation of American Hospitals, sent a joint letter to committee leaders supporting a federal legislative solution to address this issue and outlining concerns with some of the proposals discussed during the hearing. 

The provider groups advocated for legislation that limits patients’ cost-sharing obligations to the in-network amount and prohibits balance billing when the opportunity for health plans and providers to arrive at a fair payment rate is ensured. The letter expresses concerns with a newly discussed proposal that would provide a bundled payment for emergency department services. The groups challenged the suitability of bundled payments for emergent care, highlighted the administrative complexity of such a model, and pointed to concern that it might not protect patients from surprise bills.

To date, bundled billing for episodes of care has been used with mixed success only for certain types of health care services, such as planned joint replacements, for which the clinical care pathway is well defined and little variation is expected.

In stark contrast, emergency care can involve countless possible services and specialists needed to perform a wide array of diagnostic tests and complex surgeries and other procedures. As result, bundled payments and billing for emergency care would be very difficult, if not impossible, to implement.

HAP is directly vetting this and other billing policy proposals through its Surprise Balance Billing Task Force. HAP is engaging with its members, state lawmakers, the Pennsylvania Congressional delegation, national hospital groups, and other provider groups in identifying policy solutions to protect patients from surprise medical bills.

For additional information, contact Laura Stevens Kent, HAP’s vice president, federal legislative advocacy, or Jolene Calla, Esquire, HAP’s vice president, health care finance and insurance.

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