Congress passes surprise medical billing fix

Language included in the recently-passed $900 billion COVID-19 relief package will finally ban the practice of surprise medical billing – an achievement several years in the making. Congress passed the relief bill Monday night and it is awaiting President Trump’s signature.

Surprise billing happens when an individual unexpectedly receives medical care from an out-of-network provider. This can occur when a patient receives emergency services at an out-of-network emergency room, or when an out-of-network providers delivers care at an in-network facility.

A data review published by Health Affairs states that in 2014, one in five inpatient emergency department cases, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions likely resulted in a surprise medical bill.

Surprise bills can have a significant impact on the amount patients are charged for care, ranging from an increase of a few hundred dollars to other instances where patients have received surprise bills in the six figures.



The “No Surprises Act” within the new COVID relief bill specifies that patients will only be required to pay in-network cost-sharing amounts for out-of-network emergency care and care provided by out-of-network providers at in-network facilities without the patient’s informed consent. The new changes will go into effect in 2022.

The Act removes patients from plan-provider billing disputes by establishing an “independent dispute resolution” process. The bill stipulates there will be a 30-day open negotiation period during which time providers and insurers may settle out-of-network claims. If an agreement isn’t met, an independent binding arbitration process will begin.

The independent arbiter will consider the median in-network rate and other factors to settle the dispute.

The new act also specifically bans surprise air ambulance medical bills, a piece noticeably missing from state surprise billing laws. In the absence of a federal ban, individual states – like Washington, Texas, and California – have created their own surprise billing legislation. However, federal law largely blocks states from regulating air carriers and they have therefore been unable to stop air ambulance surprise billing.

Congress’s No Surprises Act does not apply to ground ambulances, which see some of the highest out-of-network billing rates of any medical specialty, but it does require the establishment of a related advisory committee.

The Act “Requires the Secretaries of Labor, HHS, and Treasury to establish an advisory committee for reviewing options to improve disclosure of charges and fees for ground ambulance services, inform consumers of insurance options for such services, and protect consumers from balance billing,” reads a document from the House Committee on Energy & Commerce.

The law includes additional transparency rules for health plans, requires timely bills for patients, and establishes a grant program for State All Payer Claims Databases.