Two Prominent Committees in the House of Representatives introduced their own legislative proposals to protect patients from unexpected out-of-network (OON) “surprise” medical bills and resolve payment disputes between health plans and providers in those situations.

Until the introduction of these two bills, a proposal from the House Energy and Commerce (E&C) and Senate Health, Education, Labor and Pensions (HELP) Committees was the leading proposal under consideration.

That bill, the Lower Health Care Cost (LHCC) Act, would establish a reimbursement rate for unexpected OON medical bills at the median in-network rate. The bill also sets up an independent dispute resolution (IDR) arbitration process for claims that exceed a certain dollar threshold. However, there are limits on the types of claims that are eligible for arbitration and how frequently a party can trigger the arbitration process.

The LHCC Act would also establish a 60-day timely patient billing requirement. Within that 60-day window, providers would have 20 days to bill a health plan, who would have 20 days to return an adjudicated claim to a provider, who would then have 20 additional days to bill the patient. Patients would not have to pay bills received after 60 days.

The LHCC Act has struggled to gain broad support from legislators and industry stakeholders. This prompted the House Ways and Means (W&M) Committee and the House Education and Labor (E&L) Committee to issue their own versions of surprise billing legislation.

All three bills include the same basic patient protections. Patients would be limited to paying their in-network cost-sharing for unexpected OON situations. Patients would also be protected from balance bills for unexpected OON services.

However, all three proposals take a different approach on how to resolve the OON reimbursement in these scenarios.

The new proposal from the House W&M Committee does not establish a reimbursement rate. The bill encourages providers and health plans to negotiate a reimbursement with each other. If those negotiations fail, the bill creates an IDR process (with no dollar threshold) to settle the disputes. Providers would also be allowed to bundle similar claims into one IDR case to reduce the administrative burden of arbitration. The bill does not establish a timely billing requirement.

The House E&L proposal would pay claims that are less than $750 at the median in network rate. Claims that exceed $750 would be eligible for an IDR process.

Congress hopes it can pass bipartisan surprise billing legislation by the end of May. However, Congress has struggled to find consensus for a proposal to advance.

That decision could ultimately come down to savings. Congress is hoping to include surprise billing legislation as part of a broader package of health care policies that must be funded before they expire in May. The surprise billing legislation savings would be used to offset the costs of the other provisions. The bill that generates the most savings could become the most attractive.

According to the Congressional Budget Office (CBO), the W&M bill would save $17.7 billion over ten years. The CBO has not issued a score for the latest version of the LHCC Act and has not yet released a score for the E&L bill.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.


Best regards,
Kirk Reinitz, CPA