Congress comes back to work as providers make push for changes to surprise billing legislation

Lawmakers are returning to work Monday to a simmering fight over how to handle surprise medical bills, with the provider industry having spent the summer pushing hard for major changes.

Provider groups have spent the monthlong August congressional recess heavily lobbying lawmakers and their staff to use an arbitration model to resolve out-of-network payment disputes instead of a benchmark rate.

A legislative package passed by the House Energy and Commerce Committee has a benchmark rate for any out-of-network charges, but with a backstop that allows both providers and insurers to head to arbitration if negotiations break down. The Senate Health, Education, Labor and Pensions (HELP) Committee passed legislation in June that used a benchmark rate.

However, neither package has gotten a vote in the full House or Senate yet.

The Energy and Commerce legislation is right now in a “holding pattern” before reaching the House floor as both the House Education and Labor Committee and the Ways and Means Committee are considering their own surprise billing legislation, a House aide told FierceHealthcare. Meanwhile, in the Senate, Republican Sen. Bill Cassidy of Louisiana and Democrat Maggie Hassan of New Hampshire have their own legislation that includes an arbitration provision.

Some provider groups are aiming to influence whatever comes out of the two House committees.

RELATED: Network matching, benchmarking remain major sticking points to surprise billing solutions

A group of 10 provider advocacy groups such as the American Medical Association, the American College of Emergency Physicians and the American College of Surgeons sent a letter to leaders of the Education and Labor and Ways and Means committees Wednesday.

The letter calls for an arbitration process that uses a “baseball-style” approach where both parties submit a final offer and the arbiter chooses one. Health insurers favor a benchmarking approach over using arbitration to solve these billing disputes.

The letter also said that “overly narrow network design by insurers has contributed significantly to the current problem. Therefore, strong oversight and enforcement of network adequacy is needed from both federal and state governments.”

Providers have taken to advertising buys and lobbying this summer to persuade lawmakers.

A group called Doctor Patient Unity—which has unknown funding sources—also launched a $2.3 million TV ad buy from late July to early August in nearly a dozen states, according to a report from the Center for Responsive Politics, which examines political spending. Most of the ads targeted Republican senators.

RELATED: One reason surprise billing solutions are so tricky for hospitals

Physicians with US Acute Care Solutions, a provider company with more than 3,000 clinicians, also lobbied congressional staff in Washington Thursday on the need for arbitration.

Some doctors with US Acute Care Solutions told reporters during a briefing Thursday that they were concerned about insurers’ ability to set the median out-of-network rate that would be used as the benchmark under the HELP and Energy and Commerce bills.

“If they are going to decide what the median amount is, every contract above the median [the insurer] will cancel to drive that median down,” said Anthony Cirillo, an emergency physician and director of government affairs for US Acute Care Solutions.

But some experts charge that the reason for surprise billing now is because of a “market failure.”

“The market failure is just that we allow anesthesiologist and these ancillary providers to negotiate with insurance plans distinct from the hospital that they work at,” said Loren Adler, a fellow at the think tank Brookings Institution at a briefing on Capitol Hill Thursday hosted by the insurance industry-backed Coalition Against Surprise Medical Billing.

Adler said that there isn’t an actual “policy reason for arbitration. There is this market negotiation between hospitals and physicians that is serving a very clean floor. Arbitration, you made it a little more opaque.”

Executive Editor Tina Reed contributed to this report.