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Draft legislation to address surprise out-of-network billing was released in mid-May by the House Energy and Commerce Committee with bipartisan support. Surprise out-of-network billing most often occurs in emergency situations where the patient has no real choice in their provider, or in non-emergency situations where a patient is being treated at an in-network facility but the medical provider at the facility is out-of-network. If the patient doesn’t know that the treatment will be processed as out-of-network, he or she will often be surprised by higher deductibles, cost sharing, and out-of-pocket limits, and may be subject to balance billing (a practice where the patient is responsible for the difference between the amount the provider bills and the amount his or her health plan actually pays).
The legislation would require the health plan to treat emergency care as in-network with regard to the patient’s cost-sharing, deductible, and out-of-pocket limits; set a minimum amount the health plan must pay out-of-network providers; and prohibit balance billing. The legislation applies to all out-of-network emergency services along with nonemergency services where the facility is in-network, but certain providers (such as anesthesiologists, radiologists, pathologists, neonatologists, and assistant surgeons) are out-of-network. Treatment by other types of non-network providers would not require in-network payment, but those providers would be required to give patients notice of their non-network status.
States have recently been passing similar legislation. However, state legislation cannot apply to self-insured plans because self-insured plans can only be regulated by the federal government. This federal legislation, therefore, would fill that gap.