Other Options
To help inform policymakers as they debate a range of patient protection options, we have identified key considerations for addressing surprise medical bills. These considerations are informed by policies already adopted in more than half of states. There are, however, other options for policymakers to consider when addressing surprise medical bills.
NOTE: Congress recently enacted the federal No Surprises Act, a new federal law that protects patients from surprise medical bills in all states. These comprehensive new protections went into effect in 2022 and protects patients from surprise medical bills for emergency services (including air ambulances) and non-emergency services provided at an in-network facility. Patients’ out-of-pocket costs will be limited to the costs they would have paid if they had received services from an in-network doctor, hospital, or other health care provider. The considerations here may continue to be relevant (especially for state policymakers interested in pursuing separate protections) but we recommend that readers learn more about the No Surprises Act here.
Other Options
To date, most of the state and federal action on surprise billing has reflected the policy considerations noted above. However, policymakers may also have other options.
Policymakers could adopt a “bundled payment” approach that would prohibit doctors who work in emergency rooms and those who provide ancillary services (such as anesthesia) from sending separate bills to patients. Because providers would be barred from independent billing, insurers would pay for these services entirely through payments to the facility at which they practice. A bundled payment would be a significant departure from the way these services are billed today, but it would simplify billing from the patient’s perspective and eliminate many instances of surprise medical bills.
A related approach—referred to as “network matching,” would require facility-based clinicians to contract with the same health plans as the facility where they practice. This approach is less disruptive to current practices than bundled payments, but it would still involve changes. Both the clinicians and the health plans would have to be willing to enter into contractual agreements either as full participants in the health plan’s network or with payment agreements to cover the relevant out-of-network situations.
As with payment standard and arbitration approaches, policymakers would need to consider the impact of these approaches on network negotiations, access, the ability of hospitals to staff emergency departments and operating rooms, and overall health costs and premiums
We Are Here to Help
Our goal is to help policymakers adopt comprehensive surprise billing protections for patients. Policymakers and staff can contact our team about a specific question or with a broader request for technical assistance. Our experts are available to review materials and consult on policy solutions.