Providers, insurers watch for Congressional action on surprise billing in 2020

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Crystal Yednak Senior Manager, Health Research Institute, PwC US January 17, 2020


Congress seemed to be moving toward a package to end surprise medical billing at the end of 2019, with President Donald Trump urging a legislative solution and proposals put forward that earned bipartisan support.

While some leading lawmakers are expressing optimism that surprise medical billing can still be tackled by Congress in 2020, others doubt the two parties will agree on anything during a contentious election year.

Legislators have been trying to respond to consumer outrage over surprise medical bills that patients may receive from out-of-network providers in situations where it may not be clear to the patient that the physician or specialist is not covered by their insurance.

Common situations where patients are surprised by expensive bills include treatment by an out-of-network doctor at an in-network emergency room, or surgery at an in-network hospital in which an out-of-network radiologist or anesthesiologist assists and the patient is not aware.

States have been passing their own legislation. New surprise billing laws in Texas, New MexicoColorado and Washington state took effect Jan. 1. The legislative solutions vary in approach, with some developing their own dispute resolution process, binding arbitration or benchmark rates for payment.

HRI impact analysis

The issue is a top concern for providers and payers heading into 2020, as providers stand to lose higher rates that may be paid in these situations and fear losing physicians and surgeons if they suffer a loss of income. If a bill gains traction again in Congress, insurers and providers are likely to carefully eye what type of negotiating process will be established for airing disputes.

More than 25 states have taken at least some kind of legislative action on surprise medical billing, establishing a patchwork of protections state by state. Complicating the matter is the reach that some of these bills have because of what states are allowed to regulate. Texas’ new law applies to only about 16 percent of Texans, according to the state Department of Insurance, because it extends only to state-regulated plans, not employer-sponsored plans or Medicare.

Consumer pressure is unlikely to dissipate, as a Kaiser Family Foundation Health Tracking Poll found in September that 78 percent of the public supports legislation protecting patients from the cost of care not covered by their insurance when the provider or hospital is not in their network. 

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Crystal Yednak

Senior Manager, Health Research Institute, PwC US

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