More on Policy and Legislation

Physicians for Fair Coverage proposes ban on surprise medical bills for out-of- network care, creation of reimbursement standards

Proposal creates a national protocol for alternative dispute resolution, which would prohibit surprise bills and establish reimbursement standards.

Beth Jones Sanborn, Managing Editor

Physicians for Fair Coverage, a non-profit, non-partisan physician alliance, has partnered with both state and national consumer organizations on a legislation model to protect patients from surprise out-of-network medical bills that they hope will inspire federal lawmakers.

The proposal seeks to ban providers and insurers from balance billing patients for unanticipated out-of-network care, also known as surprise medical bills. It creates a national protocol for alternative dispute resolution, or ADR, which is a model to prohibit surprise medical bills and establish reimbursement standards.

PFC represents thousands of physicians who serve communities throughout the country in all 50 states. PFC partners include the National Patient Advocate Foundation, the Emergency Department Practice Management Association, the American College of Emergency Physicians, the American Society of Anesthesiology, the American College of Radiology, the American Society of Plastic Surgeons, the American Psychiatric Association, the American Academy of Orthopaedic Surgeons, the American Association of Emergency Medicine, the Society of Hospital Medicine, multiple state medical societies, and dozens of other state physician and patient organizations.

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The group's proposal will allow states who have implemented an acceptable process for addressing out-of-network reimbursement to take precedence over the new federal law.

For those states without an accepted legal framework, ADR entities will be established to resolve reimbursement issues between clinicians and health insurance plans for amounts greater than $750. In those states, clinicians or plans could petition a federal ADR entity to resolve the dispute.


The group drafted the "End the Surprise Insurance Gap" on behalf of patients and physicians to promote laws that protect patients from unexpected medical costs, establish fair reimbursement standards to preserve needed access, and boost transparency.

The proposal mandates that negotiations for surprise OON services will be between providers and payers, with the patient excused from such discussions. Clinicians will provide information and discuss OON fees in before services are rendered, except in the case of emergency services or unanticipated OON care situations.

Plans must explain their out-of-network coverage and any limitations in plain language and patients will be protected from the financial impact that can result from narrow networks, retroactive denials and cost-shifting trends within insurance plans, the group said.

Additionally, on the clinician side, charges less than $750 will be directly reimbursed to the clinicians, including the patient's sharing amount, provided the charges do not exceed the 80th percentile of all clinician charges in the same geographical area for the healthcare service performed by a healthcare professional in the same or similar specialty, based on a nonprofit benchmarking database.

Timely reimbursement is also mandated, as the proposed law states that if the plan and the clinician have not agreed on a reimbursement within 30 days of claim submission, the plan must reimburse the OON clinician an agreed-upon amount based on a yet-to-be-decided formula.

Finally, insurers directly reimburse clinicians and will be prohibited from sending reimbursement to the patient. They will bill patients for their portion of the cost-sharing responsibility but will not delay payment to clinicians while waiting for payment from patients, the proposal said.

Standards on payer transparency, including accessible online and print clinician directories that offer information on when referrals are needed as well as customer service contact information, are also part of the proposal.

The group also argued against lawmakers basing reimbursement rates for out-of-network care on Medicare, since "Medicare rates were never designed to represent the fair market value of healthcare services or to even cover provider costs, and are intentionally set below market rates."


"Physicians for Fair Coverage is fighting for solutions to address the problem of surprise insurance gaps and end surprise billing for patients. We are grateful that leaders in Congress and the White House have recognized the urgency of this crisis and have committed to finding a solution that protects patients from this growing problem," said PFC's Chair, Dr. Sherif Zaafran. "As physicians, our patients are our top priority. That is why PFC has drawn on the vast expertise of its members – physicians providing care nationwide – to draft model legislation that represents an effective solution for stop surprise medical bills nationwide. Our goal is to equip lawmakers with the tools and information they need to implement effective policies that will protect all Americans from surprise medical bills while preserving access to care."

Twitter: @BethJSanborn
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