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.