The U.S. House Energy and Commerce Committee last Wednesday passed H.R. 2328, which includes a provision that hospitals support to avert cuts to disproportionate share hospitals (DSH), but also contains “surprise billing” provisions that, while better than language that had previously circulated, still restricts the ability of providers and insurers to negotiate all payments.
The DSH provision would eliminate Medicaid DSH cuts in FYs 2020 and 2021, and reduce the cut in FY 2022 to $4 billion – as opposed to $8 billion. The DSH language in the bill reflects an amendment sponsored by Rep. Joe Kennedy (D-MA) in the health subcommittee last week.
The surprise billing language comes from an amendment that passed during the bill’s markup. That amendment adds an arbitration process for hospitals and physicians that receive a median in-network payment of more than $1,250. If the payment is below $1,250, and the providers disagree with it, they have no recourse but to accept it.
Surprise billing occurs when a patient receives covered services from an out-of-network provider in an emergency situation or is treated by an out of network clinician at a facility that is in network. Just about every stakeholder, including hospitals, believe that patients should be protected from surprise bills and should pay no more than they would have paid if the service had been rendered in network. Determining how the out of network provider should be reimbursed has been more controversial. MHA believes that hospitals and insurers should use a model similar to one implemented in New York – essentially, baseball style arbitration is a backstop between the two parties if they are unable to come to an agreement on a rate. While last week’s Energy & Commerce bill does have an arbitration provision, it doesn’t kick in unless the rate exceeds the $1,250 default.
The American Hospital Association strongly opposed the surprise billing provision of H.R. 2328, saying, “It is the insurers' responsibility to maintain comprehensive provider networks, and a default payment rate would remove incentives for plans to contract with providers or to offer fair terms.”
Massachusetts legislators are working on their own surprise billing protections for patients. MHA will continue to press for a no-limit arbitration process like New York’s.
The American Hospital Association strongly opposed the surprise billing provision of H.R. 2328, saying, “It is the insurers' responsibility to maintain comprehensive provider networks, and a default payment rate would remove incentives for plans to contract with providers or to offer fair terms.”
Massachusetts legislators are working on their own surprise billing protections for patients. MHA will continue to press for a no-limit arbitration process like New York’s.