For Surprise Medical Bills, It’s the Beginning of the End

On Thursday, federal officials are expected to begin completing the particulars of how that legislative plan will translate to action, by publishing the first major regulation interpreting it. The law establishes a system for calculating a benchmark payment and a way for insurers and health providers to appeal to a neutral arbiter when they feel that amount is not appropriate.

The rule expected Thursday is not the last that will need to be published before the end of the year, but it will most likely settle several contentious issues.

Among the more important and contested provisions is a detailed definition of the “fair” price that arbiters should consider as a baseline for deciding how much the insurance plan typically owes the hospital or doctor. This will be a key figure because it will determine how much the patients owe — they are still responsible for paying the out-of-network doctor their normal co-payment or deductible amount — and what reimbursement the provider will net.

Other thorny issues being addressed in the Thursday rule include how providers must inform patients that they do not participate in their insurance network, along with the framework for a new federal complaint system. The notification rules in the law represent a new form of transparency — doctors and hospitals will need to warn patients if any of their care isn’t covered by insurance.

The complaint system will manage submissions from patients who believe their hospital or doctor is sending bills that are illegal under the new law. The law provides $500 million in funding for that new system, and gives the federal government authority to assess fines as high as $10,000 per billing violation.

Some consumer advocates worry that providers may continue billing patients in violation of the law without stringent enforcement, and will be on the lookout for rules that robustly enforce the new protections.

Subsequent rounds of regulation will provide more detail about how the arbitration process will work, and what factors the neutral arbiter can or can’t consider in deciding the right price for a medical service. Another rule is expected to deal specifically with air ambulances, which are regulated under the new law and tend to generate some of the most expensive surprise medical bills.

Sarah Kliff is an investigative reporter for The New York Times. Her reporting focuses on the American health care system and how it works for patients.


Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine.

Comments are closed.

Sign up for our Newsletter

Get the latest news about the health care industry
straight to your inbox!