Carper and advocates discuss bill to end surprise medical charges

U.S. Sen. Tom Carper, a Senate Finance Committee member, hosted a roundtable Aug. 8  with patient advocates to discuss the bipartisan STOP Surprise Medical Bills Act (S. 1531), legislation he helped introduce in May to protect patients from surprise medical bills.

Carper was joined by representatives from the National Alliance on Mental Illness of Delaware, AARP Delaware, Leukemia and Lymphoma Society of Delaware, American Lung Association, Alzheimer’s Association, Brain Injury Association of Delaware, Delaware Breast Cancer Coalition, American Heart Association, Delaware Autism, the National Association for Down Syndrome, the Delaware Insurance Commissioner’s Office and the Department of Health and Social Services.

“When I come home to Delaware every day, it is sometimes difficult to explain complex legislation Congress is working on in Washington. But the issue of surprise medical bills is not hard for Delawareans to grasp,” said Carper. “An estimated four out of 10 Americans receive medical bills that they didn’t plan for, and oftentimes, these bills can run well over $100,000. No American should have to file bankruptcy or fall into poverty as a result of a serious ailment or unexpected medical emergency. And Democrats and Republicans agree – we can do better. It’s why I’ve worked with my colleagues from both sides of the aisle on this legislation to protect patients from surprise medical bills. This bill takes the burden off of the patient. Put simply, patients should be able to focus on getting healthy rather than having to negotiate over their medical bills. Today, I’m proud to be here with patient advocates and Delawareans to discuss this common-sense legislation and figure out ways we can work together to fix this issue that is becoming all too common for too many families in our state and across the country.”

The STOP Surprise Medical Bills Act addresses three scenarios in which surprise medical billing (also known as “balance billing”) would be prohibited.

Emergency services: The bill would ensure that a patient is only required to pay the in-network cost-sharing amount required by their health plan for emergency services, regardless of them being treated at an out-of-network facility or by an out-of-network provider. 

Non-Emergency services following an emergency service at an out-of-network facility: This bill would protect patients who require additional healthcare services after receiving emergency care at an out-of-network facility, but cannot be moved without medical transport from the out-of-network facility. 

Non-Emergency services performed by an out-of-network provider at an in-network facility: The bill would ensure that patients owe no more than their in-network cost sharing in the case of a non-emergency service that is provided by an out-of-network provider at an in-network facility. Further, patients could not receive a surprise medical bill for services that are ordered by an in-network provider at a provider’s office, but are provided by an out-of-network provider, such as out-of-network laboratory or imaging services.

Providers would automatically be paid the difference between the patient’s in-network cost-sharing amount and the median in-network rate for these services, but providers and plans would have the opportunity to appeal this payment amount through an independent dispute resolution process, should they see fit. This “baseball-style” process would entail the plan and provider submitting offers to an independent dispute resolution entity that has been certified by the secretaries of HHS and the Department of Labor. This entity would make a final decision based upon commercially reasonable rates for that geographic area.

The patient is completely removed from this process between the provider and the plan, and regardless of any outcome from a dispute resolution process, the patient still only owes the in-network rate. States that have established an alternate mechanism for protecting patients and determining payment amounts for providers would be able to continue with those systems.

May 29, the Bipartisan Senate Working Group on surprise medical billing announced major growth in support for the STOP Surprise Medical Bills Act with 21 senators already co-sponsoring the legislation less than two weeks after its introduction.