Billing and Collections

Feb 25-March 1: Hospitals Push Surprise-Bill Solution

February 12, 2021 5:17 pm

Feb. 21—Hospital advocates identified specific steps recently that outlined how they hope Congress will address the contentious issue of surprise medical bills.

Six national hospital advocacy groups, including the American Hospital Association (AHA), wrote a letter to congressional leaders to identify eight key components that need to be included in any legislation to address the issue.

Those components included 

  • Defining “surprise bills”
  • Protecting patients from bills beyond cost-sharing
  • Requiring health plans to adhere to the “prudent layperson standard” that care is emergent and must be covered
  • Preserving health plan/provider negotiation
  • Removing patients from health plan/provider negotiations
  • Educating patients about their health care coverage
  • Ensuring access to comprehensive provider networks and accurate network information
  • Supporting state laws that meet minimum consumer protections

“On behalf of our member hospitals, health systems and other health care organizations, we are fully committed to protecting patients from ‘surprise bills’ that result from unexpected gaps in coverage or medical emergencies,” the hospital groups wrote.


The hospital-favored approach to the issue, which has gained bipartisan interest and action in Congress, drew critical responses from some policy advocates advising members of Congress on the issue.

Ben Ippolito, an economist at the right-leaning American Enterprise Institute, said the hospital provisions appear aimed at painting the issue as the fault of insurers.

“Frankly, this is not insurers’ fault; this is the fault of hospitals and providers not contracting,” Ippolito said in an interview.

For example, Ippolito blamed hospitals for contracting with emergency department staffing companies that they know will balance-bill every patient.

Loren Adler, associate director of the left-leaning USC-Brookings Schaefer Initiative for Health Policy, was critical of the hospital groups for urging Congress to not override state laws on the issue if they meet a minimum standard.

“Our view is that every state law to date on this issue is sub-optimal,” Adler said in an interview.

Claire McAndrew, director of Campaigns and Partnerships at the left-leaning consumer group Families USA, praised some of the hospital provisions as being good for patients but said her organization favors “a little more aggressive” effort to control healthcare costs.

Congressional Update

Although Congress is increasingly interested and active on the issue of surprise medical bills, the specific approach it will settle on remains unclear, according to policy experts.

Adler said most the discussion he has seen among legislators has focused on whether to require arbitration between health plans and providers or, instead, to set payment standards.

“I don’t think they’re decided,” Adler said about the two options.

The Brookings Institution this week introduced a package of state and federal legislative proposals to address the issue, which include limiting out-of-network charges to 125 percent of the Medicare rate.

Similarly, a bill from Sen. Maggie Hassan (D-N.H.) would preempt any state law that does not set a payment standard that providers must accept of 125 percent of Medicare rates or less.

Draft legislation from Sen. Bill Cassidy (R-La.) would bar balance billing and require insurers to pay clinicians 125 percent of usual and customary charges for out-of-network care.

McAndrew said in an interview that compromise is most likely around an arbitration-focused approach, where Congress has focused since initial discussions on establishing a payment benchmark broke down.

Ippolito agreed that the most popular approach among members of Congress and healthcare industry advocates in Washington, D.C., is legislation requiring arbitration between providers and health plans to address out-of-network patients—based on approaches used in previously enacted state laws. One such prominent state law is a 2015 statute in New York that has drawn praise from hospital advocates.

But the specific arbitration approach required by the New York law—including targeting the 80th percentile of charges among a given type of physician—was seen by Ippolito as increasing charges and fueling list-price increases.

“What we’re hearing is that it sounds like the arbitration system is not working very well,” Ippolito said. “This is one of the problems of arbitration, which is effectively rate-setting but less transparent.”

Monday, Feb. 25

Webcast of the Fourteenth National Value-Based Payment and Pay for Performance Summit in Los Angeles (through Feb. 27). Learn more.

Tuesday, Feb. 26

Webinar by HFMA titled “Financial Benefits of Setting an Effective Patient Engagement Strategy for Your Organization.” Learn more.

Hearing of the Senate Finance Committee titled, “Drug Pricing in America: A Prescription for Change, Part II.” Learn more.

Webinar for participants in the Hospital Inpatient Quality Reporting (IQR) Program titled “SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock: v5.5a Measure FAQs.” Learn more.

Webinar by CMS and the Joint Commission titled “Joint Commission Pioneers in Quality eCQM Expert to Expert Webinar Series: VTE-1 and -2 eCQMs.” Learn more.

Webinar by CMS titled “MIPS Data Submission for Year 2 (2018) of the Quality Payment Program Office Hours – Session 1.” Learn more.

Webinar sponsored by the American Hospital Association titled “Strategic Cybersecurity and Risk Issues for Health Care Leadership.” Learn more.

Wednesday, Feb. 27

Hearing by the House Education and Labor’s Subcommittee on Workforce Protections titled “Caring for Our Caregivers: Protecting Health Care and Social Service Workers from Workplace Violence.” Learn more.

Hearing by the House Energy & Commerce Committee’s Oversight and Investigations Subcommittee titled “Confronting a Growing Public Health Threat: Measles Outbreaks in the U.S.” Learn more.

Webinar by CMS titled “Eligible Clinician eCQMs with Substantive Changes for the 2019 Program Year.” Learn more.

8th Annual SVB Leerink Global Healthcare Conference in New York City (through March 1). Learn more.

Webinar by the American Bar Association titled “Getting to Know Government Attorneys: A Look at CDC and CMS.” Learn more.

Briefing by the Alliance for Health Policy titled “Basics of Biosimilars.” Learn more.

Thursday, Feb. 28

Virtual Pitch Contest by HFMA is open through March 15. Learn more.

Deadline to submit registration and attestation information for CMS’s Promoting Interoperability Programs. Learn more.

Webinar by Altarum and VBIDHealth titled “Low-Value Care 101: Identify, Measure, Reduce, Report.” Learn more.

Webinar by CMS titled “2019 QCDR Measure Workgroup: QCDR Measure Development.” Learn more.

Conference call by CMS titled “Medicare Documentation Requirement Lookup Service.” Learn more.

Webinar sponsored by AHIP titled “Preparation for 2020: Implementing Supplemental Benefits into Your Plan.” Learn more.

Webinar by CMS titled “Comparative Billing Report: Family Practitioner Office Visits.” Learn more.

Friday, March 1

Deadline for providers in BPCI Advanced to withdrawal without penalty. Learn more.

Deadline to report any small breaches of unsecured protected health information (PHI) that were discovered in 2018. Learn more.

Comments due on the Centers for Medicare & Medicaid Services’ Medicare Advantage and Part D advance notice and draft call letter. Learn more. 


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