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Hospitals Give Congress 8-Point Checklist for 'Surprise Bills' Legislation

Analysis  |  By Steven Porter  
   February 21, 2019

The joint letter comes two months after major payer groups outlined a framework of their own, as the industry debates who's to blame for unexpected medical bills.

Six major hospital groups sent a joint letter Wednesday to lawmakers on Capitol Hill, where a rare show of bipartisan political will seems to be forming around the potential for legislation to combat surprise medical bills.

The groups acknowledged the stress and financial burden unexpected bills can have on patients, and they gave Congress a checklist to consider in drafting legislation to address the problem.

Their letter came two months after health plans outlined a framework of their own, in a joint letter with business and consumer groups, highlighting the competing interests at play among industry players who have at times blamed each other.

"We must work together to protect patients from surprise bills," the hospital groups' letter states, outlining a checklist with eight critical items for legislators to consider:

1. Define 'surprise bills.'

The hospital groups said surprise bills typically occur in three scenarios: (1) when someone uses out-of-network emergency services, such as while traveling, (2) when someone uses out-of-network physician services at an in-network hospital, and (3) when a health plan declines to cover emergency services deemed to be unnecessary.

2. Protect the patient financially.

Providers should not engage in balance billing, the letter states.

"Patients should have certainty regarding their cost-sharing obligations, which should be based on an in-network amount," the hospital groups wrote.

3. Ensure patient access to emergency care. 

Patients should be able not only to access emergency services but also enjoy coverage for those services without having to self-diagnose in advance, the letter states.

"This requires that health plans adhere to the 'prudent layperson standard' and not deny payment for emergency care that, in retrospect, the health plan determined was not an emergency," the hospital groups wrote.

4. Preserve the role of private negotiation. 

Lawmakers shouldn't empower the government to set fixed payments or reimbursement for healthcare services that are out-of-network, as that "could create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks," the letter states.

5. Remove the patient from health plan/provider negotiations. 

"Patients should not be placed in the middle of negotiations between insurers and providers," the hospital groups wrote. "Health plans must work directly with providers on reimbursement, and the patient should not be responsible for transmitting any payment between the plan and the provider."

6. Educate patients about their health care coverage. 

Providers, health plans, employers, and others should all seek to boost healthcare literacy among patients, they argued.

"We urge you to include an educational component to help patients understand the scope of their health care coverage and how to access their benefits," the hospital groups told lawmakers.

7. Ensure patients have access to comprehensive provider networks and accurate network information.

Health plans should be giving patients easy-to-understand information about their provider network, and regulators should make sure both that the health plan provider networks are adequate and that provider directors are accurate, the hospital groups wrote.

8. Support state laws that work. 

With a nod to state-led efforts to protect patients from surprise bills, the hospital groups said federal policies should account for various state laws.

"Any federal solution should provide a default to state laws that meet the federal minimum for consumer protections," they wrote.

The letter was signed by six organizations: the American Hospital Association, America's Essential Hospitals, Association of American Medical Colleges, Catholic Health Association of the United States Children's Hospital Association, and the Federation of American Hospitals.

Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand.

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