Viewpoint: Congress should broaden legislation to end medical price-gouging

Federal lawmakers have worked on legislation to address surprise medical bills, but these proposals must be broadened to help all patients, including the insured and uninsured, says George A. Nation III, a professor of law and business at Bethlehem, Pa.-based Lehigh University, in a post published by The Hill.  

Seven takeaways:

1. In September, a bipartisan group of senators unveiled the Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democratic Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical Bills Act of 2018, and Democratic Sen. Jeanne Shaheen, also of New Hampshire, filed a companion bill. Rep. Michelle Lujan Grisham, D-N.M., also introduced billing legislation in the House last year.

2. The legislative efforts largely focus on surprise medical bills. These can occur when patients through no fault of their own receive care from an out-of-network provider and and the provider charges the difference between the provider's charge and the insurer's allowable out-of-network amount. This may occur for example when a patient is taken to an out-of-network facility during an emergency.

3. Mr. Nation argues patients unfairly receive surprise medical bills, and medical price gouging contributes to this because patients who receive unexpected out-of-network medical bills lose the benefits of in-network rates set by their insurer and are commended to pay high list prices.

4. The No More Surprise Medical Bills Act of 2018 isn't broad enough because it does not protect self-pay patients from medical price-gouging, Mr. Nation said.

5. A companion bill to the No More Surprise Medical Bills Act of 2018, introduced Oct. 3 by Sen. Jeanne Shaheen, D-N.H. protects all self-pay patients from medical price-gouging because it "strikes at the heart of the chargemaster-based pricing system by establishing a method for determining a fair price for medical care," said Mr. Nation.

6. But Mr. Nation took issue with states' options under the companion bill. The legislation allows states to set prices based on one of the following: 125 percent of the Medicare rate; 80 percent of the "usual, customary and reasonable charge for the service, as determined by a database of usual, customary and reasonable charges chosen by the applicable state authority and approved as appropriate by the secretary" of state; or the insurer's allowed in-network charge for service.

7. He argued the Medicare-based rate should apply in emergency situations, and the average contract rate, per contracts between hospitals and in-network insurers, should be an option for nonemergency care, if the hospital contracts with at least three in-network insurers.

Access Mr. Nation's full article here.

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