TMA Keeps Pressing Congress on Surprise Billing
By Joey Berlin


As lawmakers continue their work on a federal solution to surprise medical bills, the Texas Medical Association is on guard to make sure patients will be protected – and physicians get a fair shot to get paid properly.

TMA joined 18 other state medical and specialty societies on a letter last week  to the chairs and ranking members of three U.S. House committees: Energy and Commerce, Education and Labor, and Ways and Means. Those lawmakers include Texas Rep. Kevin Brady (R-The Woodlands), ranking member of Ways and Means.

Congress is working on a bipartisan solution to out-of-network care disputes involving company health plans under the federal Employee Retirement Income Security Act, which cover the vast majority of health insurance consumers. Some of the competing proposals have incorporated “baseball-style” independent dispute resolution (IDR), in which an arbitrator or mediator makes an either/or selection between a figure submitted by the physician and one submitted by the health plan. TMA, the American Medical Association (AMA), and others in organized medicine support baseball-style IDR.

Texas’ new law on surprise bills involving state-regulated plans includes an IDR process. So does a recent federal proposal by Representative Brady and Ways and Means Committee Chair Richard Neal (D-Mass.).

TMA’s letter urges the legislators to adopt a series of guidelines for dispute resolution to help arrive at a balanced, fully informed decision on payments, including: rates for comparable services in the same geographic region based on an independent database of commercial-payer claims; demonstration of good-faith efforts by either the practitioner or health plan to enter into network contracts; and complexity of the services rendered.

The letter cautions that federal surprise-billing legislation should avoid references to median in-network rates, which insurers have pushed to become a payment benchmark. Such a yardstick “would be tantamount to a national fee schedule, thereby reducing access to in-network physicians and increasing health care costs by driving consolidation in the health care market,” TMA’s letter says. And the committees should compel plans to “provide appropriate physician and provider networks” to meet patients’ needs.

Along with baseball-style dispute resolution, TMA’s letter urges the lawmakers to make sure any final legislation maintains several “essential” components already included in federal proposals. Among them:

  • Protecting patients who receive unanticipated medical care by ensuring that they’re responsible only for their in-network cost-sharing, including deductibles;
  • Keeping patients out of the middle of payment disputes by providing physicians with direct payment/assignment of benefits from the insurer;
  • Providing an open negotiation period to encourage practitioners and health plans to voluntarily resolve payment disputes; and
  • Not setting a dollar threshold for make claims eligible for dispute resolution.

Signatories on the March 4 letter include AMA; TMA’s medical-society counterparts in California, Florida, and Massachusetts; the American College of Emergency Physicians; and the American Society of Anesthesiologists.

You can read more about the federal surprise-billing debate in this month’s issue of Texas Medicine magazine.


Last Updated On

February 10, 2023

Originally Published On

March 09, 2020

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