Federal legislation that would protect Americans from unexpected or “surprise” medical bills has stalled in Congress due to policy disagreement on exactly how to reimburse the out of network provider in “surprise” billing situation. To date, 28 states have enacted some form of consumer protections that address surprise billing which has helped push lawmakers to create federal policies. Generally defined, surprise billing refers to unanticipated bills from circumstances in which patients were serviced at an in-network medical facility but received treatment by an out-of-network provider.

While Congress is divided on the policies around reimbursing out-of-network providers for surprise billing situations, Congressional staff involved in these negotiations are confident an agreement will be reached that will move legislation forward in upcoming weeks.

Each Chamber has advanced their own version of surprise billing legislation through the Committee process. Both Chambers are waiting to break the stalemate before holding a floor vote.

The Senate bill, S. 1895, the Lower Health Care Cost (LHCC) Act and the House bill, H.R. 3630, the No Surprises Act, both include similar patient protections. However, they differ on the OON reimbursement policy. The LHCC Act would establish the median in-network rate as the OON payment while the No Surprises Act would establish an arbitration process to determine the OON payment.

The health plan and large employer groups support the LHCC Act’s rate setting approach while affected provider groups support the No Surprises Act’s arbitration approach.

According to the Congressional Budget Office, both the LHCC Act and the No Surprises achieve considerable savings for the federal government. The CBO states that the LHCC Act would save $25 billion over ten years while the No Surprises Act would save $20 billion over ten years.  Further, the CBO says both bills achieve savings by lowering provider reimbursements which will lower insurance premiums which will lower federal premium assistance payments for Affordable Care Act (ACA) plans. Finally, according to the CBO, the No Surprises Act saves less money than the LHCC Act mainly because of the administrative costs associated with the arbitration process.

According to Congressional staff, the negotiations are ongoing but there is optimism that a consensus can be reached in time to attach a final version of surprise billing legislation to a must-pass government funding bill in November.

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

Best Regards,

Kayley Jaquet

Manager of Regulatory Affairs