AES Sign-on to AMA Letter to Congress Regarding "Surprise Billing" Legislation

Dear Chairman Pallone and Ranking Member Walden:

The undersigned organizations believe a fair and equitable independent dispute resolution (IDR) process is an essential component of any surprise billing solution and should be included in any final bill coming out of the House Energy and Commerce Committee to ensure the legislation is balanced and does not result either in unfair payments to physicians or unreasonable bills to health plans. We fully support the central goal of the No Surprises Act to protect patients from surprise medical bills when they unknowingly receive services from out-of-network providers in in-network facilities. We also support the provisions in the No Surprises Act that would ensure patients are only responsible for in-network cost-sharing in these situations, and that their cost-sharing count toward in-network deductibles and out-of-pocket maximums. We also agree that patients should be taken out of any payment disputes between physicians and insurers that arise from these situations.

However, once the patient is protected from surprise medical bills, it is equally important to ensure that the legislation does not create new imbalances in the private health care marketplace by undermining the ability of doctors to secure fair reimbursement for their services. The health insurance marketplace is already heavily consolidated. Instituting a federal government rate-setting scheme that allows private insurers to force discounted rates on physicians, hospitals and other health care providers based on their median 2019 in-network rates puts both network and non-network providers at a disadvantage and will result in sudden drops in reimbursement for emergency and nonemergency hospital-based care. This will create patient access problems, particularly in rural areas and other underserved populations that are already experiencing health care provider shortages. In fact, the California Department of Managed Health Care reports consumer access to care complaints have increased 48% since California passed its surprise billing law. There are also preliminary reports that California insurers are seeking to drive down in-network median payments by dropping providers from their network who are currently paid above the median.

The undersigned organizations believe that legislation should include a fair IDR process narrowly tailored to resolve payment disputes regarding noncontracted out-of-network care. Such a process should be set up to incentivize health plans to make a fair initial offer of payment for out-of-network care rendered to their customers and discourage physician bills that are outside of generally acceptable ranges. It also should encourage, rather than discourage, both parties to contract for in-network care. The process should be structured to include a range of factors to be considered in the case of an appeal; factors such as the complexity of the service rendered, the experience of the physician providing the service, the rate that physicians charge for the service in a geographic area, and insurance data from an independent source. We recommend the Committee look to the states for examples of where such appeals processes are working to resolve payment disputes in a manner both insurers and providers perceive as fair without negatively impacting patient access to hospital-based services or premiums.

Sincerely,