Spending Package Addresses ‘Surprise’ Medical Billing

A ban on “surprise” medical billing is part of the major spending bill and COVID-19 relief package that Congress is expected to vote on Monday.

The legislation will protect patients from being billed in situations such as going to the emergency room and getting care from a physician who is out of network or not covered by the patient’s insurance plan. Consumers have complained about receiving bills for thousands of dollars when they receive emergency care in an out-of-network facility or are treated by an out-of-network doctor during an emergency or surgical event.

President Donald Trump called on Congress to fix the surprise billing issue two years ago. But Congress had struggled to reach an agreement during that time.

The health care industry agreed that patients should be held harmless in emergency situations. But hospital and physician groups and insurers fought over who would pick up the tab. Congressional committees struck a compromise deal earlier this month, Politico reported.

That compromise deal called for health insurers and providers to negotiate most billing disputes or bring their complaints to a mediator. But the final version of the bill would forbid arbiters from taking into account Medicare and Medicaid rates, which are typically much lower than what commercial coverage pays.

That is a loss for insurers, employers who fund a major piece of private coverage, and patient advocates who thought including those public rates as a barometer could help curb health care prices. The measure also bars arbiters from considering providers' billed charges, which are usually well out of line with what insurers or patients end up paying.

In addition, Congress also appears to have watered down a measure that would have required health insurers to disclose detailed information to employers about their drug costs and rebates through their contracts with pharmacy benefit managers.

PBMs’ business practices have come under scrutiny in recent years for their role in high drug costs. Instead, the legislation calls for insurers to submit more general information on medical costs and prescription drug spending to relevant federal agencies, which would feed into a government report on drug pricing trends.