Surprise Medical Bills

Every day, thousands of Americans are admitted to hospitals to utilize different medical services. Though they are able to receive the diagnostic services and treatment they need, some get stuck with surprise bills they cannot afford because their health insurer does not have a proper network of physicians.

This usually occurs when patients receive care at an in-network hospital that does not have an adequate network of specialty physicians who are in their insurance networks. This leaves patients left to cover the bill. This happens through no fault of their own, it is the result of a health insurer not contracting with the necessary physicians to serve their enrollees.

Download our Understanding Surprise Bill Infographic (PDF)

Why We Are Calling for Congressional Action

Something must be done. We have three policy suggestions that aim to relieve the anxiety patients experience from surprise medical bills:

  1. Hold patients harmless - Patients do not need additional financial stress during this vulnerable time, let alone the hassle of trying to rectify the situation. We are asking Congress to keep patients out of the middle and create an Alternative Dispute Resolution (ADR) system where insurers and providers settle their differences.
  2. Set network advocacy standards - Most surprise bills are a result of inadequate networks. It is common sense that more in-network doctors at a facility will result in fewer surprise out-network bills. It is why -we are pushing for legislation to enforce regulations that mandate enough in-network providers available at a given facility. Insurance companies should not narrow networks to shift financial responsibility to patients. Learn more about network adequacy.
  3. Fair reimbursement for quality care - To ensure health plans pay a fair rate for physician services, there must be an independent database that verifies the market rate of these services. Payments should reflect the market value of the service based on charges and commercial payments for the service for each geographic area where the service is provided.

Answers to Your Surprise Billing Questions

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The House Ways and Means Committee has released bipartisan legislation entitled the Consumer Protections Against Surprise Medical Bills Act. The bill offers specific patient protections and a mediated dispute resolution process. Read more on the Way and Means website.

For bills that the CAP views as favorable to patients and pathologists, we recommend that any arbitration process should remove restrictions mandating that claims must be above a specific dollar amount or threshold. To maximize efficiency, providers should be allowed to batch claims for the same or similar services under the same insurance provider. We also signed a letter to the House Ways and Means Committee on essential provisions needed to protect patients from surprise bills. Read the letter.

Familiarize yourself with our policy positions and watch for emails from the CAP that will prompt you to send a message to your representative or senators in Congress. Your response to our alerts to take action is critical to our success! Read the issue brief.