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Surprise Medical Billing Debate Continues

Healthcare Alert | February 14, 2020
By: Lori Smith, Andy Hamelsky, Luke Repici and Zaara Nazir

In an ongoing effort to pass legislation addressing surprise medical billing, the U.S. House of Representatives moved two proposals out of committee this week. The crux of the competing legislation is how much an insurer will pay an out-of-network provider. The House Ways and Means Committee put forth a proposal that follows the model preferred by hospitals and providers, as it does not include a formula for fixing reimbursement rates and instead relies on using a two-step process to resolve disputes over out-of-network bills.

The proposal provides for a 30-day negotiation period to exchange information and attempt resolution between the parties. If the matter is not resolved through negotiation then either party can initiate a mediation process with an independent third party. While there are no set rates, the mediator will consider the median contracted rate specific to the plan, and for similar providers, services, and geographic areas.

In contrast, the House Education and Labor Committee bill uses a blended process of set rates and arbitration. A benchmark rate would be used for care under $750. This rate would be set at the median in-network price for a service in a given geographic region. For amounts exceeding that threshold, parties can initiate an arbitration process. The dispute resolution model is the approach preferred by payers.

These two proposals differ from previous proposals we reported on (1 and 2) as legislators attempt to find the right mix to appease patients, providers and payers. We anticipate that there will continue to be a push to pass legislation in the coming months and will continue to monitor and report on progress toward this goal.

If you have questions or would like additional information, contact Lori Smith (; 212.714.3075), Andy Hamelsky (; 212.631.4406), Luke Repici (; 215.864.7066), Zaara Nazir (; 973.604.5681) or another member of the Healthcare Group.

This correspondence should not be construed as legal advice or legal opinion on any specific facts or circumstances. The contents are intended for general informational purposes only, and you are urged to consult a lawyer concerning your own situation and legal questions.
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