Surprise Billing and Observation Status Gain Momentum in Congress

May 16, 2019
Policy Snapshot

This week a bipartisan group of senators introduced a piece of legislation to help end surprise medical billing. The STOP Surprise Medical Bills Act calls for an arbitration process for settling disputes between providers and insurers. Under the bill, arbitration would be an option providers and insurers could use if they are unhappy with the payment they receive as a result of out-of-network services. The Senate bill would ensure that a patient only pays in-network cost-sharing rates for emergency services and would protect patients who are taken to out-of-network facilities in emergency situations. The legislation also would ensure that patients owe no more than their in-network rates if they are unwittingly treated by an out-of-network provider at an in-network facility.

A similar bill, known as The No Surprises Act, was introduced in the House. It ties a benchmark payment rate for out-of-network services to the average in-network rate for that geographic area but does not include arbitration. It also requires that patients receiving scheduled care receive written and oral notice at the time of scheduling about the provider’s network status and any charges they could incur. If a patient does not sign a consent form acknowledging that they know they are seeing an out-of-network provider, the patient cannot be billed for the balance. Also, the legislation provides $50 million in grants for states to set up an all-payer claims database.

Another issue that has been affecting patients is “observation status” and Medicare coverage of skilled nursing facility (SNF) care. The House Ways and Means Health Subcommittee has indicated they will take up the issue and The Improving Access to Medicare Coverage Act of 2019 in a hearing because of its surprise billing implications for Medicare beneficiaries. The Society has long supported The Improving Access to Medicare Coverage Act of 2019, which would enable all time spent in the hospital to count toward the Medicare three-day inpatient status requirement for SNF coverage. Click here to tell your elected officials to support the bill.