Healthcare industry publishes balance-billing guide as senators pose legislation

As momentum builds on Capitol Hill for legislation to curb outsize or surprise medical bills, provider and insurance trade groups have released a consumer guide on balance billing—a sign they are aware of policy discussions on the issue.

The serious legislative push on the issue started in September, when Sen. Bill Cassidy (R-La.) and a bipartisan group of co-sponsors from the Senate Health and Finance committees introduced a draft bill that would cap what patients have to pay when they find themselves with a surprise balance after a hospital visit.

Then early this month, Democratic New Hampshire Sens. Maggie Hassan and Jeanne Shaheen released complementary bills targeting the same practice, although the details of how the two bills enforce the protections differ.

The federal proposals follow multiple actions on the state level to rein in balance bills. However, states don't have the authority to regulate large employer plans—a heavy limitation as balance bills become more and more common for people with insurance.

Major industry stakeholder groups have yet to weigh in publicly on these recent legislative proposals. But on Wednesday America's Health Insurance Plans, American Hospital Association and the Healthcare Financial Management Association released a 15-page guide on the issue, starting with detailed explanations of how provider and insurance network negotiations work.

A spokesperson for AHA said the guide, a follow-up to a previous brief released several years ago, is unrelated to the legislation and has been in the works for a long time.

The guide advises patients to ask where a scheduled procedure will take place and whether any other physicians or specialists will be attending—a nod to the common issue of patients of an in-network hospital finding themselves charged high rates when an out-of-network physician participates in a procedure.

To avoid emergency balance billing, the guide suggests keeping a list of near-by emergency departments.

"Check whether the emergency departments on your list are in network," the guide states. "Go to your health plan first and check the online directory or speak with customer service. Then contact the hospital or health system that operates the emergency department to confirm that they are in network."

The guide will be distributed broadly through providers and community partners, an AHIP spokesperson said.

Its release comes as policy experts and analysts praise the Senate measures as a game changer—or "monumental change," as Claire McAndrew of the advocacy group Families USA said—even if they want to see some tweaks to the details.

"As written, Hassan's bill would nearly eliminate surprise out-of-network bills for enrollees in employer-provided health plans," policy experts with the Washington think-tank Brookings Institute wrote this month.

The same authors in a Health Affairs article described the Cassidy bill as "an important step forward in putting an end to surprise out-of-network medical bills nationwide."

McAndrew sees reverberating impact not only on the highest sticker-shock balance bills that get the most attention, but also the lower-amount surprise bills that are either pricey enough to squeeze patients or confusing enough to drive them away from their provider.

"The models offer protection that is completely beyond what we have now," McAndrew said. "It's very exciting to me. This really is real."

While the exact next steps and timeline for the proposals are unclear, their sponsoring legislators have been adamant that they want to get something done early in the next Congress.

"Given the bipartisan interest in this issue, Senator Hassan is hopeful that the [Senate health committee] will mark-up legislation in the future to address surprise medical bills for Granite Staters and Americans," a Hassan spokesperson said, adding that the senator has been in touch with Cassidy's office on the matter.

The Senate health committee has throughout 2018 been holding hearings on reducing healthcare costs, and committee senators raised the idea of balance billing curbs in June.