Surprise medical bills— also known as surprise out-of-network “balance bills”— are a particularly egregious health care cost, as they are unpredictable for families and occur despite every effort consumers make to avoid them. Surprise medical bills occur when people are charged for care from out-of-network providers or facilities that they receive due to no fault of their own. These bills can amount to hundreds, thousands, or even tens-of-thousands of dollars.

Surprise medical bills are incredibly common. One-in-five emergency department visits result in a surprise medical bill and nearly 70 percent of air ambulance patient transports are out-of-network. These surprise bills are the result of a systemic problem that places families in the middle of a tug-of-war between health care providers and insurers over the price of services.

As organizations that represent consumers, patients, and workers, we call on Congress to enact legislation to ban surprise medical billing immediately. Such legislation must comprehensively protect consumers while ensuring health care costs don’t inflate.

 

Three Key Principles for Surprise Medical Bill Legislation

Principle One: Ban Surprise Balance Billing and Fully Protect Consumers

  • Balance billing should be completely prohibited in any care situation where consumers cannot ensure they will see an in-network provider or visit an in-network facility, including in emergencies, at in-network facilities, and for air and ground emergency transit.
  • For out-of-network care that individuals incur due to no fault of their own, they should pay no more than in-network cost-sharing (including copayments, co-insurance, and deductibles).
  • Out-of-pocket spending should count towards a consumer’s in-network out-of-pocket maximum and deductible.
 

Principle Two: Contain Total Costs for Consumers  

  • To ensure that insurance premiums or overall health care costs aren’t unfairly increased, a reasonable payment level between insurers and out-of-network providers for surprise bill situations must be established.  
  • A reasonable payment level should be based on actual prices being paid in the market, and not be inflationary (e.g., should not be based on billed charges, which almost always do not accurately reflect price).
 

Principle Three: Ensure Comprehensive Protection Nationwide

  • Federal law should apply to surprise bill situations unless state law is equally or more robust in terms of consumer protections.  Federal law should determine the payment level owed by a plan to a provider in a surprise bill situation except when a state law already established a payment level prior to passage of federal law. If the federal law covers surprise bill situations not covered by an established state law, the federal law should wrap around the state law to set the payment rate in those situations.
  • Even if states have robust surprise billing laws, federal law should apply to any situations that states cannot fully regulate, such as self-insured, ERISA-regulated plans and air ambulance bills.