WASHINGTON, D.C. – U.S. Senator Sherrod Brown (D-OH) hosted a news conference call today as he urged Congress to act on his bipartisan STOP Surprise Medical Bills Act, legislation to protect patients from surprise medical bills. There have been astounding examples reported in the media of patients receiving surprise medical bills, like the patient from Ohio who faced significant medical bills after receiving care for a heart attack from a medical provider outside of his insurance network.

“When you’re rushed to the hospital for a heart attack, the last thing you or your loved ones should have to worry about is whether the nearest hospital is in-network,” said Senator Brown. “Ohioans work hard and pay their insurance premiums every month and this bill makes sure it will be there for them if an emergency happens.”

Brown was joined today by Charlene York, a southwest Ohioan whose daughter was billed $3000 after she was taken to an out-of-network facility for emergency care. Her daughter was covered under two different insurance plans at the time.

“My family has a rare disease that involves muscular dystrophy and pulmonary issues.  We have had an experience two years ago in which we received a surprise medical bill due to a life or death medical emergency.  Despite having two health insurances, our daughter was charged $3,000 for being out of network,” said Ms. York.  

Brown’s STOP Surprise Medical Bills Act addresses three scenarios in which surprise medical billing (also known as “balance billing”) would be prohibited:

  • Emergency services:  The bill would ensure that a patient is only required to pay the in-network cost-sharing amount required by their health plan for emergency services, regardless of them being treated at an out-of-network facility or by an out-of-network provider.
  • Non-Emergency services following an emergency service at an out-of-network facility: This bill would protect patients who require additional health care services after receiving emergency care at an out-of-network facility, but cannot be moved without medical transport from the out-of-network facility.
  • Non-Emergency services performed by an out-of-network provider at an in-network facility: The bill would ensure that patients owe no more than their in-network cost sharing in the case of a non-emergency service that is provided by an out-of-network provider at an in-network facility. Further, patients could not receive a surprise medical bill for services that are ordered by an in-network provider at a provider’s office, but are provided by an out-of-network provider, such as out-of-network laboratory or imaging services.

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 plans would have the opportunity to appeal this payment amount through an independent dispute resolution process, should they see fit. This “baseball-style” arbitration process would entail the plan and provider submitting offers to an independent dispute resolution entity that has been certified by the Secretaries of HHS and the Department of Labor. This entity would make a final decision based upon specific factors, including the commercially-reasonable rates for that geographic area.

Brown introduced legislation in 2017, the End Surprise Billing Act, which would protect patients experiencing a medical emergency from being charged more than in-network rates for emergency care. The bipartisan STOP Surprise Medical Bills Act builds on Brown’s bill to ensure the patient is completely protected and only owes the in-network rate, but also goes a step further in determining payments for providers. States that have established an alternate mechanism for protecting patients and determining payment amounts for providers would be able to continue with those systems.

A study from the Georgetown University Health Policy Institute reviewed the implementation of a similar law to address surprise medical billing in New York. New York’s law takes patients out of the middle of payment disputes between providers and plans and uses a “baseball-style” approach to settle payment disputes when the providers and plans can’t reach an agreement on their own.

The study found that state officials have seen a “dramatic” decline in consumer complaints about surprise medical billing since the law went into effect, that independent arbitrator decisions were essentially even between plans and providers, and that the vast majority of cases were resolved before needing to go to arbitration.

Click here to see the section-by-section summary of the bill.