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. The following solutions suggested by the Coalition Against Surprise Medical Billing are bipartisan, common-sense reforms to best ensure that patients can get the care they need at costs they can afford, including:

Banning balance billing in situations where patients are involuntarily treated by an out-of-network provider. This includes: (a) emergency health care services provided at any hospital; (b) ambulatory transportation to any health care facility in an emergency; and (c) any health care services or treatment performed at an in-network facility by an out-of-network provider not selected by the patient.

Requiring health insurance providers to reimburse non-participating doctors or clinicians based on local market rates negotiated by other doctors in the area. All health plans should be required to reimburse a non-contracted hospital or health care provider in the above scenarios based on the market-rate negotiated by other doctors in the same service area. 

If no such rate is ascertainable, then the plan should be obligated to pay the applicable Medicare rate for the service. These requirements should be applied to all ERISA self-funded health plans, and non-ERISA and insured plans, with the option for states to establish similar standards, so long as the state methodology would not increase patient cost-sharing or premiums.

Avoiding a cumbersome arbitration process that increases costs for patients, businesses and taxpayers. Health care is already confusing. In states where arbitration is common, it adds another layer of red tape because it’s long, complicated, unpredictable and costly. Surprise medical bills are often based on little more than what a non-network provider hopes to be paid.

Under arbitration, these excessive charges are given equal weight to reasonably negotiated rates. Any process that rewards these outrageous charges, the end result will be payments that are excessively high – which will increase premiums for patients. And, since the federal government provides premium tax credits and other health care cost support, when premiums go up, taxpayer costs go up right along with them. Establishing a fair, market-based benchmark for out-of-network charges would mitigate the likelihood of excessive costs for patients and the taxpayers. 

To view the Coalition’s principles, click here

Take Action

Tell Washington it’s time to protect patients from surprise and unfair medical bills.