A bipartisan group of lawmakers produced a deal on surprise billing legislation that is more provider-friendly than legislation previously passed by U.S. Senate and House committees, but hospitals still oppose the deal.
Senate health committee Chair Lamar Alexander (R-Tenn.), House Energy & Commerce Chair Frank Pallone (D-N.J.) and Energy & Commerce Ranking Member Greg Walden (R-Ore.) on Sunday announced a compromise on legislation to lower healthcare costs, including a ban on balance billing. The White House issued a statement in support of the legislation, and said it was the result of "months of delicate work" and "reflects the input of doctors and hospitals."
The deal lowered the threshold for providers to pursue arbitration over out-of-network charges, but the tweak was not enough to gain support from providers.
American Hospital Association CEO Rick Pollack said the compromise would give too much leverage to insurers at the expense of hospitals.
"It remains highly problematic and would jeopardize patient access to hospital care," Pollack said.
Greater New York Hospital Association President Kenneth Raske voiced similar concerns and criticized lawmakers for their focus on including legislation in an end-of-year spending deal.
"This rush to get surprise billing language into an end-of-year funding bill, without regard to real-world consequences to healthcare providers, is dangerous and unnecessary," Raske said.
It is unclear whether either House or Senate leadership is supportive of the bill. While Senate Majority Leader Mitch McConnell (R-Ky.) has said he supports a provision of the bill that would raise the tobacco purchasing age to 21, lobbyists tracking the legislation say leadership in both chambers may be loath to force their members to vote on an issue that divides powerful interests.
Under the legislation, patients would be held harmless in balance billing disputes and insurers would have to pay providers at least the median in-network negotiated rate in the area. If the median in-network rate is higher than $750, providers could appeal the payment rate in a baseball-style arbitration process, according to a summary of the legislation. Providers would not be able to bundle charges to bring them to an arbiter.
The American College of Surgeons said the $750 threshold for arbitration is still too high.
"A significant number of physician-provided services have less than a $750 charge. For all those services, the physician would be forced to accept initial payment," the group said in a statement.
Previous legislation from the Senate health committee did not include an arbitration backstop at all, and the House Energy & Commerce legislation set a higher arbitration threshold at $1,250.
"No patient should ever receive a surprise medical bill. However, this package takes two steps forward and three steps back," said Chip Kahn, the president and CEO of the Federation of American Hospitals.
In the process outlined in the compromise legislation, an outside arbitrator would have to consider providers' training, education and experience, parties' market share, and other extenuating factors when making a determination. It is unclear whether an arbitrator would be directed to consider some sort of benchmark rate.
Air ambulance carriers would also be banned from balance billing, and insurers would pay at least the median in-network negotiated rate in the area. If the rate is higher than $25,000, carriers could appeal to an outside arbitrator.
The Association of Air Medical Services opposed the legislation.
"AAMS has been working with members of Congress to develop legislation that would create transparency in the industry and take patients out of the middle, as well as collect data for proper reimbursement," AAMS said in a statement. "However, we continue to see legislation that will have a devastating impact on the air ambulance community, with no data and very little research, move forward."
The new package retained hospital and insurer contract reforms that were in the Senate health committee's legislation on lowering healthcare costs. A provision from the Senate legislation that would have required all bills to be sent to a patient within 45 days of discharge was changed to give providers and plans 60 days to get a bill to the patient.
Savings from the compromise would extend funding for community health centers, the National Health Service Corps, teaching health centers and the Special Diabetes Programs for five years.