The Solution

Everyone in America deserves affordable, high-quality coverage and care, and control over their health care choices. Surprise medical bills undermine these values, putting the health and financial stability of millions of patients at risk every year. As organizations representing America’s accountable care providers, employers and health insurance providers, we all have a role to play in ensuring that patients are informed, engaged, and protected from excessive costs. While the passage of the No Surprises Act was a first step towards protecting patients from surprise medical billings, the implementation of the legislation must adhere to the original goals of law with the following priorities:

Reduce health care costs by maintaining reasonable, market-based payments to out-of-network providers.

  • Allow health plans to make initial payments that reflect market conditions and keep consumers’ costs low. 
  • Reinforce the qualifying payment amount (QPA) is based on contracted rates, not paid claim amounts. 
  • Explicitly prohibit use of certain third-party databases to arrive at QPAs.
  • Allow calculations methodologies to account for non-Fee-for-Services arrangements. 

Ensure broad protections against unfair, surprise medical bills by establishing clear definitions around the scope of services affected by the law.

  • Establish clear prohibitions around ‘balance billing’ for the scope of services affected by the law. 
  • Implement consumer-friendly processes for advanced-care notifications from out-of-network providers. 

Avoid a cumbersome arbitration process that increases costs for patients, businesses and taxpayers.

  • Prevent abuse of IDR by limiting the scope of claims eligible for ‘batching’ 
  • Certify IDR entities that are free of conflicts of interest and possess minimum qualifications 
  • Reinforce the QPA as the primary criterion for choosing between two reimbursement offers. 
  • Requiring transparency and reasonable fees and IDR entities.

To view the Coalition’s principles, click here.