Draft Legislation to Limit Surprise Out-of-Network Bills

Last month, a bipartisan group of Senators released draft legislation protecting consumers from surprise medical bills from out-of-network providers. These surprise bills often arise when a patient visits an in-network emergency department, but the physician that treats him or her is out-of-network. Surprise bills also affect patients in non-emergency situations: a patient could seek an in-network facility and an in-network primary physician, but ancillary medical providers—like radiologists or anesthesiologists—may unknowingly be out-of-network.

In situations like these, the draft legislation would first limit the patient’s cost-sharing to what he or she would owe to an in-network provider. Insurers would then only pay the provider either the median in-network contracted rate for the service or 125% of the average allowed amount for the service. Finally, the legislation would prohibit the provider from balance billing the remainder.

Many state governments have implemented similar legislation recently, and the federal government may soon be following in their footsteps.