Washington, D.C. — U.S. Senator Susan Collins announced that bipartisan legislation to protect patients from surprise medical bills was signed into law as part of the government funding package.
Americans increasingly pay more out-of-pocket for their health care, so it is crucial that they have access to the information they need to make informed decisions. The health and economic crisis we are currently experiencing due to COVID-19 has underscored the need for Congress to come together to increase the affordability and accessibility of medical care.
“Far too many Americans are struggling with the skyrocketing cost of health care, which places severe strain on family budgets and threatens access to the care and medications they need. The last thing patients should have to worry about while they are sick or recovering is receiving an unexpected bill because they were unaware they were receiving out-of-network care,” said Senator Collins. “Increasing the affordability and accessibility of health care is one of my highest priorities, and this new law ending the unfair practice of surprise medical billing will help provide significant relief.”
The proposal to end surprise medical billing will also allow approximately $18 billion in savings to be used to fully fund Community Health Centers, Teaching Health Centers Graduate Medical Education, and Special Diabetes Programs for three years. As the lead sponsor of the Training the Next Generation of Primary Care Doctors Act, Senator Collins has long worked to bolster and expand this successful training program. As the founder and co-chair of the Senate Diabetes Caucus, she has championed the Special Diabetes Program, which has been instrumental in promoting advances in diabetes care such as the artificial pancreas system.
The bipartisan, bicameral agreement protects patients and establishes a fair payment dispute resolution process including:
- Holds patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts, including deductibles, in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider.
- Prohibits certain out-of-network providers from balance billing patients unless the provider gives the patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care.
- Creates a framework that takes patients out of the middle, and allows health care providers and insurers to resolve payment disputes without involving the patient.
- Under the agreement, insurers will make a payment to the provider that is determined either through negotiation between the parties or an independent dispute resolution (IDR) process. There is no minimum payment threshold to enter IDR, and claims may be batched together to ease administrative burdens.
- If the parties choose to utilize the IDR process, both parties would each submit an offer to the independent arbiter. When choosing between the two offers the arbiter is required to consider the median in-network rate, information related to the training and experience of the provider, the market share of the parties, previous contracting history between the parties, complexity of the services provided, and any other information submitted by the parties.
- Following an IDR process, the party that initiated the dispute may not take the same party to arbitration for the same item or service for 90-days following a determination by the arbitrator. However, all claims that occur during the 90-day period are eligible for IDR after the 90-days.
- Provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers.
- Empowers consumers by providing a true and honest cost estimate that describes which providers will deliver their treatment, the cost of services, and provider network status.