Not a Nice Surprise

Surprise medical billing is a real problem across the country and – since the passage of the Affordable Care Act (ACA) – affects people everywhere. With the ACA’s government mandated changes, insurance companies narrowed physician networks to control costs, offering less robust coverage than we had before the government takeover of the health insurance market. This, in turn, is adversely impacting patient access, as physicians are increasingly feeling the need to negotiate for a fair reimbursement price for their services. The result has caused more patients to receive care from providers who are out-of-network. Patients often see sky-high bills and suffer from stress and even financial ruin because of medical bills. This needs to end.

Last week, the House Education and Labor Committee, of which I am a senior member, marked up their own surprise billing legislation. This legislation takes the patient out of the middle but includes a government-set price for physician services, effectively taking away the only negotiating power that physicians have. It only allows physicians to negotiate for claims that are above $750 through arbitration, but most claims – especially emergency room services with an average reimbursement rate nationwide around $150 – would never be eligible for IDR no matter how strong the disagreement. I joined a bipartisan coalition who voted against this proposal because of how unfair it is to physicians. If we are serious about solving this problem, we need a fair system – one that does not hand the control over to either side but keeps patients safe from receiving a surprise medical bill ever again.

The good news is everyone in Congress agrees patients should be taken out of the middle in these billing disputes. Over the last year, Congress looked at different proposals on how best to address this issue and all of them protect patients from these stressful bills. Legislation I introduced with Rep. Ruiz (D-CA), the Protecting People from Surprise Medical Bills Act, would take patients completely out of billing disputes by leaving it to the providers and insurers to work it out using an independent dispute resolution process (IDR), more commonly known as “baseball-style arbitration.” It is based on a highly successful model in New York state first enacted in 2014. According to a study by Georgetown University Health Policy Center– as of October 2018 – the New York IDR process saw 618 decisions favor the health plan while 561 favored the provider. The process is proven to be fair to both providers and payers.

Opponents of our approach have claimed setting up arbitration will result in an overuse of the arbitration process, but that’s not what the data shows. Out of the millions of claims filed each year across the state, only 1,179 cases in four years were decided by an arbiter using IDR.

The New York IDR process is never cited by an insurance company as a reason for increasing premiums since enactment. Also, in contrast to the claims of those who oppose the IDR process and support federal price fixing, it has not added costs to the health care system.

Thankfully, the Chairman and Ranking Member of the House Ways and Means Committee introduced a better bill that is very similar to my legislation that includes a robust arbitration process. During the markup of their bill, they received overwhelming support in the committee, and it passed by a voice vote. The president is engaged on this issue. He even tweeted after both bills passed that he applauds both committees for passing legislation and wants a final bill on his desk. I appreciate the president calling attention to this issue and am glad he is keeping us focused on what matters in this debate – protecting patients.

I will continue working with my colleagues in the House and Senate to strike the right balance that protects patients, favors neither providers nor insurers and maintains patient access to care.

Source: U.S. Representative Phil Roe, M.D.