Surprise Medical Billing

Special interest groups have pushed the Tennessee General Assembly during the past few years to address the issue of “surprise medical bills,” including filing a bill to remove the state’s ban on the corporate practice of medicine. TMA wants to reach a solution – at the state or federal level – that frees patients from the financial burden of unexpected out-of-network charges while protecting physicians’ rights to choose how they practice and get paid appropriately for services they provide.

OUR PRINCIPLES

  • Hold patients harmless for out-of-network charges without removing Tennessee's ban on the corporate practice of medicine, prohibiting balance billing or obstructing physicians' right to be fairly compensated for the services they provide.

  • Hold health plans accountable to patients with reasonable network adequacy standards.

  • Do not allow insurance companies to set their own reimbursement rates without negotiating with physicians and other healthcare providers.

  • Create a fair arbitration process to resolve payment disputes between providers and payers, and keep the patient out of it.


STATE ADVOCACY

Balance billing is one of TMA’s top legislative priorities in 2020, and TMA has worked with Sen. Bo Watson and Rep. Timothy Hill to file a placeholder caption bill to address the issue. SB 2684 / HB 2680 is based on the independent dispute resolution (IDR) model in New York, where balance billing claims make up less than 2% of all claims in the state.

TMA will continue advocating for a state-level solution that is fair to all parties, especially physicians and patients, in lieu of any federal solution.

FEDERAL ADVOCACY

Congress in summer 2019 began considering multiple proposals to protect patients from surprise medical bills. Legislators in both chambers agree that the first priority is protecting patients from unexpected charges for out-of-network care, but some of the proposed legislation would amount to price fixing, more leverage for insurance companies and more heavy-handed government interference in the delivery of care.

It appeared Congress was fast-tracking legislation in late 2019 to allow insurance companies to effectively set rates physicians would be paid for out-of-network services. Negotiations have continued in 2020 and two notable proposals are on the table.

  • The Consumer Protections Against Surprise Medical Bills Act of 2020 (HR 5826) was introduced in the House Ways and Means Committee in February 2020. The bill differs from other surprise billing legislation because it does not include a payment benchmark for “surprise” medical bills. It encourages insurers and providers to negotiate privately to solve payment disputes and establishes an IDR process in the event private negotiations fail. It requires the mediation entity in an IDR situation to consider the “median in network rate” as determined by the insurer, and specifically prohibits consideration of the "usual and customary" charges or the provider's billed charges. Physician advocacy groups are asking the Committee to include provisions in the bill for objective, independent data sources in IDR to ensure a fair process. Using median payments would give health plans incentive to drive down in-network rates and threaten patient access to care.

  • The Ban Surprise Billing Act (H.R. 5800) passed out of the House Education and Labor Committee in February 2020. It would use a benchmark rate to settle payment disputes for claims at or below $750 and allow for IDR for claims above $750. The Committee ignored warnings from physician advocates like TMA and some lawmakers about how the bill would lead to more narrow networks and essentially create government rate setting. The committee rejected amendments to revise the benchmark rate or expand access to an IDR process. 

TMA continues working closely with the American Medical Association, Physicians Advocacy Institute, and state and national medical specialty societies to send a uniform message to lawmakers and make sure that Tennessee physicians have a voice in federal policies affecting healthcare in Tennessee. Physician advocacy groups agree that the best way to hold patients harmless and preserve their access to hospital-based specialty care, including emergency services, is to implement IDR using independent data – not health plans’ median rates or arbitrary government rates – and stronger network adequacy standards and oversight.