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senate Bill S. 1531

Should Patients be Protected From Surprise Medical Bills?

Argument in favor

Surprise medical bills are an unwelcome surprise for too many Americans. This bill would set a new process for ensuring that patients seeking needed care aren’t financially burdened by their pursuit of medical services.

Renee's Opinion
···
08/26/2019
Yes. Patients should be provided an estimate of the cost for services provided prior to treatment.
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jimK's Opinion
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08/26/2019
There are two issues. First, you generally have no good idea how much the total bill for an emergency room visit or hospital stay could be. There are generally quite a few services and specialists involved who each contribute to the total bill. Second, it is often unclear what the health insurer has negotiated as the acceptable pricing for these services and what they will actually cover. Sure, you cannot know all of the costs in advance because there may be additional needs depending upon your condition and other factors requiring medical attention. Solutions include having negotiated norms for charges that the provider must adhere to if they are to be listed with an insurer, requiring insurers to have clear cut rules for coverage that are clearly defined for insurance purchasers, have insurance provider exchanges which include these details as well as public user ratings of the quality of insurance services provided, and allowing users to periodically change plans based upon their own trade-off of cost vs coverage vs quality. Medicare part A and B provides clear, consistent coverage and excellent negotiated 'acceptable' charges for services. It could be better, but it is an excellent starting place, As an example, my wife recently had spinal surgery involving spinal fusions and a bunch of other stuff. The total provider charges exceeded $300,000.00. The total of Medicare payments and coverage from a good supplemental insurance plan was on the order of $30,000 and I had no out-of-pocket expenses at all. I pay a lot extra for the combination of part B and supplemental insurance but at our age it seems very worth the extra cost. The point is, that without the Medicare or other insurer's negotiated allowable charges, the overall paid-for costs would be fully 10 times greater! The providers of scheduled services know very well what is covered and what is not per a persons insurance plan. They generally have assessed your ability to pay before scheduling procedures and they could and certainly should provide a realistic ball park estimate to prospective patients- allowing them to trade-off medical urgency vs financial jeopardy.
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Amy's Opinion
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08/26/2019
Cannot believe this has to be put into law. Only thing in the US that we literally can’t live without, health care, and we go into surgery or other life saving treatments and we have no idea what we will owe. How stupid is this! We don’t even handle car repairs or medical care for our pets this way! We are some of the most gullible people on this Earth. And people say single payer is going in the wrong direction! Seriously. Wake up America!
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Argument opposed

The arbitration provision in this bill is opposed by some industry groups that say it’s a “snipe hunt” that distracts from broader issues regarding health services pricing. It could also wind up being more expensive than other pricing models, such as network pricing or regulated prices.

Alex's Opinion
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08/26/2019
This doesn’t address the ridiculous costs of American healthcare. We need Medicare for all.
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David's Opinion
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08/26/2019
This clearly is a backdoor approach to universal health insurance. There are no surprises when you sign a contract with your health insurance company and they follow the contract.
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NoHedges's Opinion
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08/26/2019
Nay, this piece of “new legislation” follows a very predictable pattern. 1. Headline asks a stupid question 2. Sponsored by a Republican 3. Research reveals “new legislation” being purposed is either a remake with less support for the voters or it is simply a piece of legislation being duplicated from one department to another. 4. I vote no, and wonder when Republicans are going to get serious about their image as sentient humans.
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bill Progress


  • Not enacted
    The President has not signed this bill
  • The house has not voted
  • The senate has not voted
      senate Committees
      Committee on Health, Education, Labor, and Pensions
    IntroducedMay 16th, 2019

What is Senate Bill S. 1531?

This bill — the STOP Surprise Medical Bills Act of 2019 — would protect patients from surprise medical bills in three situations: 1) emergency services, 2) non-emergency services following an emergency service at an out-of-network care facility and 3) non-emergency services performed by an out-of-network provider at an in-network facility. It would also protect patients that receive out-of-network laboratory or imaging services ordered by an in-network provider at their office from those surprise bills. In all of these scenarios, this bill would limit patients’ liability to the in-network cost-sharing, and patient-cost sharing for these services would accrue toward the in-network deductible and out-of-pocket maximum. Providers or plans/issuers who violate the surprise billing ban would be subject to civil monetary penalties. 

To handle billing disputes, the Health and Human Services (HHS) Secretary would consult with the Labor Secretary to certify entities to perform independent dispute resolution (IDR). These entities, which would be unbiased and unaffiliated with health plans/issuers and providers, would work with plans and providers to resolve billing issues. Patients would be completely removed from the IDR process, which would be “baseball-style” (meaning each party submits one final offer, and the loser pays, such that the non-prevailing party would pay for IDR process costs for the prevailing party). 

This bill would also include a number of transparency and notification requirements for various parties: 

  • Providers with contracts with health plans/insurers to provide in-network services to enrollees would be required to notify contracted providers of any new insurance products the provider would be eligible for within seven days of offering the new product;
  • Health plans/issuers would be required to clearly list in-network and out-of-network deductibles on insurance cards issued to their enrollees;
  • Providers and plans/issuers would be required to tell patients and enrollees the expected cost-sharing for the provision of specific health care services within 48 hours of request;
  • Providers/issuers would be required to make available price information for services available online to help patients know costs upfront;
  • Hospitals would be required to disclose any financial relationships or profit-sharing agreements they have with physician groups on their website(s) and printed material(s);
  • Hospitals would be required to include ancillary services on the bills they send to patients;
  • Group health plans and issuers would be required to provide the HHS Secretary and Labor Secretary with annual reports on 1) the total claims submitted, paid and denied; 2) out-of-pocket costs to enrollees for out-of-network claims and the amount the plan/issuer paid; and 3) the numbers of out-of-network claims reported for emergency care and out-of-network claims for care performed at in-network facilities. 

This legislation would allow states with their own surprise billing laws to choose their own methodologies to resolve surprising billing disputes. Therefore, states wouldn’t have to adopt the IDR framework.

The HHS and Labor Secretaries would work together to study this legislation’s effects. They would submit a report to Congress on: 

  • The financial impact on patient responsibility for health care spending and overall health care spending;
  • The incidence and prevalence of the delivery of out-of-network health care service;  The adequacy of provider networks offered by health plans/issuers;
  • The impact of connecting reimbursement to different claims databases;
  • The number of bills that go to the independent dispute resolution process; and
  • The administrative cost of the IDR process and estimated impact on insurance premiums and deductibles.

This bill’s full title is the Stopping The Outrageous Practice of Surprise Medical Bills Act of 2019.

Impact

Medical patients; medical billing; surprise medical billing; health care providers; health care plans; medical billing disputes; and arbitration of medical billing disputes.

Cost of Senate Bill S. 1531

A CBO cost estimate is unavailable.

More Information

In-DepthSponsoring Sen. Bill Cassidy (R-LA) introduced this bill to protect patients from surprise medical bills

“Patients should be the reason for the care, not an excuse for the bill. We have worked for almost a year with patient groups, doctors, insurers and hospitals to refine this proposal. This is a bipartisan solution ensuring patients are protected and don’t receive surprise bills that are uncapped by anything but a sense of shame.”

Original cosponsor Sen. Michael Bennet (D-CO) adds

“The last thing a patient should have to worry about is being blindsided by unanticipated, and potentially financially devastating, medical bills. People deserve to know how much they are paying for health care services and procedures at the point of care. Our bill would help protect patients from surprise medical bills, increase transparency and alleviate the financial burdens imposed on consumers as a result of these bills. I urge my colleagues to prioritize this bipartisan legislation to give much needed relief and predictability to Americans throughout the country.”

The National Coalition on Health Care supports this bill. Its president and CEO, John Rother, says

“This bipartisan proposal would ensure that no patient will ever again be subject to outrageously high ‘surprise bills’ as the result of a hospital visit. Americans should have confidence that they will be treated fairly the next time they visit an emergency room. The National Coalition on Health Care commends Senators Cassidy and Hassan for their leadership on this issue, and we urge swift consideration by the Congress. Health care is expensive enough without families being subjected to price gouging just when they are most vulnerable.”

President Trump has promised to sign some form of surprise billing legislation.

Some Capitol Hill insiders say the arbitration provision in this bill could be a hurdle to getting this legislation over the finish line. At a Ways and Means Committee hearing on this issue, a representative from the trade group representing employer plans called the proposal a “snipe hunt” used by providers and hospitals to distract Congress from fixing deeper issues in the American healthcare system.

There may also be a case to made against arbitration from a cost-control perspective. Some experts believe having a regulated price or network matching, rather than allowing arbitration, is better policy because arbitration could end up leading to higher prices than the other two options, mitigating the cost-saving potential of surprise billing legislation.

This legislation has 26 bipartisan cosponsors, including 14 Democrats and 12 Republican. It also has the support of the National Coalition on Health Care and the National Patient Advocate Foundation.


Of NoteThe arbitration approach this bill proposes is already in use in some areas. For example, New York state law already removes patients from payment disputes between providers and plans and uses the baseball-style approach to settle payment disputes (this was implemented in 2014). 

In a Georgetown University Health Policy Institute study, researchers found that New York state officials saw a “dramatic” decline in consumer complaints about surprise medical billing after New York switched to the baseball dispute resolution process. They also found that independent arbitrator decisions were essentially even between plans and providers, and that the vast majority of cases were resolved before needing to go to arbitration.

Surprise medical bills, also known as “balance bills,” are issued to consumers who generally mistakenly thought they were getting health services covered by their insurers but instead went to an out-of-network provider. In such cases, insurance often covers a small portion of services and the patient is responsible for the remainder (the “balance”). In some cases, the consumer can be responsible for paying the entire bill. Most surprise bills come from specialty physicians — such as anesthesiologists, radiologists and emergency room doctors.


Media:

Summary by Lorelei Yang

(Photo Credit: iStockphoto.com / DNY59)

AKA

Stopping The Outrageous Practice of Surprise Medical Bills Act of 2019

Official Title

A bill to amend the Public Health Service Act to provide protections for health insurance consumers from surprise billing.

    Yes. Patients should be provided an estimate of the cost for services provided prior to treatment.
    Like (65)
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    This doesn’t address the ridiculous costs of American healthcare. We need Medicare for all.
    Like (57)
    Follow
    Share
    There are two issues. First, you generally have no good idea how much the total bill for an emergency room visit or hospital stay could be. There are generally quite a few services and specialists involved who each contribute to the total bill. Second, it is often unclear what the health insurer has negotiated as the acceptable pricing for these services and what they will actually cover. Sure, you cannot know all of the costs in advance because there may be additional needs depending upon your condition and other factors requiring medical attention. Solutions include having negotiated norms for charges that the provider must adhere to if they are to be listed with an insurer, requiring insurers to have clear cut rules for coverage that are clearly defined for insurance purchasers, have insurance provider exchanges which include these details as well as public user ratings of the quality of insurance services provided, and allowing users to periodically change plans based upon their own trade-off of cost vs coverage vs quality. Medicare part A and B provides clear, consistent coverage and excellent negotiated 'acceptable' charges for services. It could be better, but it is an excellent starting place, As an example, my wife recently had spinal surgery involving spinal fusions and a bunch of other stuff. The total provider charges exceeded $300,000.00. The total of Medicare payments and coverage from a good supplemental insurance plan was on the order of $30,000 and I had no out-of-pocket expenses at all. I pay a lot extra for the combination of part B and supplemental insurance but at our age it seems very worth the extra cost. The point is, that without the Medicare or other insurer's negotiated allowable charges, the overall paid-for costs would be fully 10 times greater! The providers of scheduled services know very well what is covered and what is not per a persons insurance plan. They generally have assessed your ability to pay before scheduling procedures and they could and certainly should provide a realistic ball park estimate to prospective patients- allowing them to trade-off medical urgency vs financial jeopardy.
    Like (46)
    Follow
    Share
    Cannot believe this has to be put into law. Only thing in the US that we literally can’t live without, health care, and we go into surgery or other life saving treatments and we have no idea what we will owe. How stupid is this! We don’t even handle car repairs or medical care for our pets this way! We are some of the most gullible people on this Earth. And people say single payer is going in the wrong direction! Seriously. Wake up America!
    Like (37)
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    Protect Americans from predatory health insurers!
    Like (28)
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    Universal single payer healthcare system NOW
    Like (21)
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    This kind of legislation barely even scratches the surface of the problems with our healthcare system and really just seems like an attempt by Congress to make it appear that they’re actually doing something substantial on healthcare. If you really want to protect people, pass Medicare-for-all!
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    Yes, of course, Americans should be protected from hidden medical expenses. I have had the good fortune to have lived in both Canada (10 years) and the Netherlands (3 years), where medical expenses are covered and much lower on a per patient basis. In the USA, healthcare has unfortunately become a wealth-extraction sector. Most of the politicians have become captured by for-profit HC company bribes.
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    As with any transaction you should have all the information and cost presented to you before services are rendered.
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    This clearly is a backdoor approach to universal health insurance. There are no surprises when you sign a contract with your health insurance company and they follow the contract.
    Like (10)
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    Yes
    Like (8)
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    Patients should fully know what they need to pay so that they can fully plan on how to pay it so that they won’t be surprised by a new bill which could potentially ruin their financial future.
    Like (8)
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    The fact that we have to ask is scary
    Like (7)
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    Yes, common sense legislation
    Like (6)
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    This is an absolute must! Please pass a bill to protect people from healthcare billing. Transparency is absent from this area and has to improve.
    Like (6)
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    Nay, this piece of “new legislation” follows a very predictable pattern. 1. Headline asks a stupid question 2. Sponsored by a Republican 3. Research reveals “new legislation” being purposed is either a remake with less support for the voters or it is simply a piece of legislation being duplicated from one department to another. 4. I vote no, and wonder when Republicans are going to get serious about their image as sentient humans.
    Like (6)
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    I fully support and recommend passage of this bill as written. #MAGA
    Like (5)
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    This is a no brainer, once you went through all the works with the hospital, doctor and insurance that you are approved for a procedure, only to find out some non preferred “Slimball” stepped in and billed you. The hospital should eat this. This has to stop!
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    We need transparency in medical costs to give Americans the ability to control their medical spending. In what other cases do we receive something, either a service or good, and legally bound to pay for it before we have at least a cost estimate? If a car repair costs 10x the estimate, I am not bound to the contract. Medical services should be no different.
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    I totally agree with jimK on his statement below. Yes we should know what these services should cost prior to the service being rendered. But due to the fact this proposal is repugnant backed makes me say No. There are two issues. First, you generally have no good idea how much the total bill for an emergency room visit or hospital stay could be. There are generally quite a few services and specialists involved who each contribute to the total bill. Second, it is often unclear what the health insurer has negotiated as the acceptable pricing for these services and what they will actually cover. Sure, you cannot know all of the costs in advance because there may be additional needs depending upon your condition and other factors requiring medical attention. Solutions include having negotiated norms for charges that the provider must adhere to if they are to be listed with an insurer, requiring insurers to have clear cut rules for coverage that are clearly defined for insurance purchasers, have insurance provider exchanges which include these details as well as public user ratings of the quality of insurance services provided, and allowing users to periodically change plans based upon their own trade-off of cost vs coverage vs quality. Medicare part A and B provides clear, consistent coverage and excellent negotiated 'acceptable' charges for services. It could be better, but it is an excellent starting place, As an example, my wife recently had spinal surgery involving spinal fusions and a bunch of other stuff. The total provider charges exceeded $300,000.00. The total of Medicare payments and coverage from a good supplemental insurance plan was on the order of $30,000 and I had no out-of-pocket expenses at all. I pay a lot extra for the combination of part B and supplemental insurance but at our age it seems very worth the extra cost. The point is, that without the Medicare or other insurer's negotiated allowable charges, the overall paid-for costs would be fully 10 times greater! The providers of scheduled services know very well what is covered and what is not per a persons insurance plan. They generally have assessed your ability to pay before scheduling procedures and they could and certainly should provide a realistic ball park estimate to prospective patients- allowing them to trade-off medical urgency vs financial jeopardy.
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