Texas Physicians Weigh in on Federal Surprise Billing Solution
By Joey Berlin

Surprise_Burgess

As Texas prepares to implement an arbitration process to address surprise medical bills, Texas physicians are helping the U.S. Congress work on a federal solution. 

The House Committee on Energy and Commerce’s Subcommittee on Health tackled surprise billing in a hearing last week to consider the No Surprises Act, draft legislation put together by two committee members. 

Rep. Michael Burgess, MD (R-Lewisville), above, the only Texas physician in Congress and a member of the subcommittee, participated in the hearing, along with Houston anesthesiologist Sherif Zaafran, MD, chairman of the board for Physicians for Fair Coverage (PFC). 

Texas Gov. Greg Abbott last week signed Senate Bill 1264, which introduces a baseball-style arbitration process for surprise medical bills stemming from certain out-of-network care. That process will take the patient out of the middle of the dispute, leaving health plans and physicians to make their cases to an independent arbitrator about what payment amount is fair. (See the August issue of Texas Medicine magazine for an in-depth look at SB 1264.) 

Noting in his written remarks that 12 states have now adopted baseball-style independent dispute resolution, Dr. Zaafran recommended such a process at the federal level. 

“We believe protecting patients by eliminating balance billing and ensuring patients pay no more than their in-network cost sharing is the right thing to do,” Dr. Zaafran told the subcommittee in his written remarks. Dr. Zaafran is also president of the Texas Medical Board. 

Dr. Zaafran wrote that federal intervention also must include:

  • Ensuring a fair payment on a case-by-case basis for physicians who provide services to out-of-network patients;
  • Protecting “the vast majority of the in-network contracted marketplace” to avoid incentivizing and generating more out-of-network claims; and
  • Creating an incentive for out-of-network physicians to join networks, and for health plans to bring more physicians in-network. 

Although each baseball-style model is different, Dr. Zaafran said in his written testimony, “they all have the same basic framework in common – the patient is protected; both parties have recourse to a neutral third-party … if they believe the other party is unreasonable; each party is incentivized to provide their most reasonable offer; and the parties are incentivized to remain or go in-network and avoid the dispute resolution process.” 

In his opening statement at the hearing, Representative Burgess noted:  “While Texas and numerous other states have made efforts to mitigate the billing issues, states are unable to legislate what happens in cases involving multi-state, employer-sponsored plans.” 

Everyone involved in the balance-billing conversation should agree that patients should be held harmless so they can avoid massive bills, he said. 

“It is important that throughout this conversation, we consider the potential effect of shifting payment incentives for physicians, for insurers, [and] for hospitals, and that we’re not driving payment rates too far in one direction or the other,” Representative Burgess added. 

The draft of the No Surprises Act, introduced by Rep. Frank Pallone, Jr. (D-N.J.) and Rep. Greg Walden (R-Ore.) would ensure that a patient’s cost-sharing for a surprise out-of-network bill “is limited to what the individual would have paid if the services were provided by an in-network provider,” according to opening remarks by Representative Pallone. It would require health plans to pay the physician a minimum of the median in-network rate for the service in question in that geographic area. 

Other organizations sending witnesses to the hearing included the American Hospital Association, America’s Health Insurance Plans, and the American College of Emergency Physicians. 

Meanwhile, across the rotunda, Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member of the Health, Education, Labor and Pensions Committee, laid out their own plans earlier this week for paying for surprise medical bills.

Last Updated On

June 19, 2019

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Joey Berlin

Associate Editor

(512) 370-1393
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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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