October 06, 2017

Surprise Billing Legislation Introduced in House

On September 29, H.R. 3877, titled the “Fair Billing Act of 2017” was introduced in U.S. Congress. The legislation seeks to amend title XVIII of the Social Security Act to address surprise billing practices by banning balance billing within in-network facilities. Facilities would not be able to hold the individual liable for more than the amount that the individual would have been required to pay in cost sharing if such items or services had been furnished by an in-network facility.

Exceptions to bill the patients would be granted in cases where pre-approved written consent was obtained and for emergency services. The legislation suggests that each state may elect to establish a review process to be available at the request of a health care plan or service provider. Failure to establish an external review process and relevant standards would result in the Secretary of the Department of Health and Human Services selecting a review process for the state.

The legislation proposes two ways an independent health care expert could determine how much insurers would pay out-of-network providers. One is the lesser of an amount proposed by the provider and an amount equal to the 80th percentile of the sum for the provided services as reported to a national all-payer claims database (or a designated state or regional all-payer database). The other is based on the greater of an amount proposed by the provider and 125 percent of the Medicare fee schedule payment rate for the service.

H.R. 3877 is sponsored by Rep. Michelle Lujan Grisham (D-NM) and has been referred to the House Energy and Commerce and Ways and Means committees.