White House, Congress Enter Fray Over Surprise Billing

Published June 13, 2019

In a May 9 White House briefing, President Donald Trump saidtoo many Americans are saddled with medical bills “for services they did not know anything about, and sometimes services they did not have information on.”

“So, this must end,” said Trump. “We’re going to hold insurance companies and hospitals accountable.”

Joining Trump at the briefing was a patient and her father who talked about a $17,850 bill for a urine drug screening incurred during a hospital visit.

Trump said more announcements of efforts to improve transparency would follow, stating, “This will be something that will have a big impact, maybe an even bigger impact than the health-care bill.”

Surprises on the Rise

Surprise medical bills have risen as an issue as insurers and large employers show a clear preference for provider networks, which can manage costs but give consumers more flexibility than health maintenance organizations. Patients who choose or are treated by a provider outside their network may face steep out-of-pocket charges. In particular, patients receiving emergency care or hospital care may be treated by an out-of-network specialist, such as an anesthesiologist, who will present a bill for services rendered. The resulting unexpected charges can run into the thousands of dollars.

Hospitals, insurers, and medical providers have expressed sympathy for such patients but have not been able to agree on a way to resolve the issue. Though the policy framework is still a work in progress, the Trump administration appears to favor legislation or an executive order to increase price disclosure, perhaps even compelling providers and insurers to make public the rates and discounts they have between each other, arrangements they consider proprietary. In February, the Department of Health and Human Service put out notice seeking comment on whether patients have a right to see such information.

The White House also says it wants doctors and hospitals to disclose the full price of care before a patient undergoes treatment, regardless of whether the provider is in the patient’s insurance network. The White House has stated the president opposes mandating an arbitration process in which a third party would decide the cost of a medical service under dispute between provider and consumer.

Bipartisan Bills

Bipartisan draft legislation dealing with surprise billing and price transparency is under consideration in the House and Senate.

A House draft pointedly called the “No Surprises Act” was drafted and released for feedback by Rep. Frank Pallone (D-NJ), chairman of the Energy and Commerce Committee, and the committee’s ranking member, Rep. Greg Walden (R-OR). Among other things, the proposed legislation would prohibit surprise medical bills and hold patients harmless in emergency situations and when a patient cannot reasonably choose a provider, according to a discussion draft for comment. 

Two bills are being floated in the Senate.

On May 16, the Senate Bipartisan Working Group, led by Sen. Bill Cassidy (R-LA) and Michael Bennett (D-CO), introduced legislation that, among other things, would mandate that patients are required to pay only the in-network cost-sharing amount required by their health plans for emergency services, regardless of whether they are treated at an out-of-network facility or by an out-of-network provider.

Setting up a possible confrontation with the White House, the bill also includes a baseball-style arbitration process. Providers would automatically be paid the difference between the patient’s in-network cost-sharing amount and the median in-network rate for these services, but providers and insurance plans would have the right to appeal this payment amount through an independent dispute-resolution process.

The other draft legislation, released on May 23 by Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA), would require providers and health plans to give patients good-faith estimates of their expected out-of-pocket costs for health services within 48 hours of a request.

Possible Executive Action

Price transparency is also at the center of several executive actions expected shortly from the Trump administration. The Wall Street Journal in two separate articles on March 7 and March 11 reported the president wants to peel back the secrecy surrounding the prices charged to patients. One idea under consideration would have the Labor Department issue a rule to force insurers to publicize the negotiated rates they pay for services. The reports also state the administration is considering an upcoming hospital outpatient rule to require hospitals to disclose their negotiated rates with insurers. Both actions could face challenges, according to the reports, by hospitals and insurers.

“Transparency for transparency’s sake, and forced disclosure of thousands upon thousands of competitively negotiated rates, will not help consumers,” Matt Eyles, president of America’s Health Insurance Plans, told The Wall Street Journal. “Instead, it will cause health-care costs to go up for every American.”

Burdens on Patients, Providers

The system urgently needs price transparency, says Marilyn Singleton, M.D. and J.D., a California-based anesthesiologist.

“Patients should not be the victims of the insurance plan’s flawed protocols regarding out-of-network services,” said Singleton. “Patients should only be responsible for in-network cost-sharing rates when faced with unanticipated medical bills. All patients who choose to obtain scheduled care from out-of-network physicians, hospitals, or other providers should be informed of the amounts the insurer will cover and the out-of-pocket expenses, prior to receiving the services.”

Singleton says in many cases neither medical providers nor patients are able to discuss likely bills for services rendered before treatment begins.

“When a patient is wheeled into the operating room on an emergency basis, we are discussing the patient’s medical history, not his or her insurance status,” said Singleton. “Moreover, at that point the patient is not in a position to seek care elsewhere.”


Bonner R. Cohen, Ph.D., ([email protected])is a senior fellow at the National Center for Public Policy Research and a senior policy analyst with the Committee for a Constructive Tomorrow (CFACT).