Surprise out-of-network bills arise when a consumer receives care from an out-of-network provider in a situation she cannot reasonably control, such as being treated by an out-of-network anesthesiologist at an in-network hospital. These bills are common for emergency and ancillary care — studies suggest that about 20 percent of emergency department visits and 10 percent of elective inpatient care stays involve at least one out-of-network provider.
Surprise billing reflects a market failure: patients do not choose their emergency and ancillary physicians, so the flow of patients these physicians receive depends on the hospital in which they practice, not the prices they charge or whether they join insurer networks. As a result, they have an out-of-network billing opportunity not available in other specialties, and many leverage that option not only to send large surprise bills, but also to demand very high in-network payment rates when they do enter insurers’ networks.
Federal and state policymakers are considering steps to end surprise billing, but leading proposals often do not go far enough to reduce excess spending. In fact, some proposals intended to address surprise billing could actually end up increasing spending on the services most vulnerable to surprise bills. On the other hand, well-crafted proposals can both protect patients from surprise bills and bring down premiums.
Experts analyze the market for air ambulance services and provide solutions to managing high prices.
Addressing surprise billing could substantially affect commercial insurance premiums. In addition to protecting patients from receiving unexpected bills, policies to address surprise billing could reduce health insurance premiums by 1% to 5%.
This article estimates the prevalence and magnitude of privately insured persons’ out‐of‐network air ambulance bills, describes the legal barriers to curtailing surprise air ambulance bills, and proposes policies to protect consumers from out‐of‐network air ambulance bills.
Emerging policy solutions to surprise medical bills
Watch an event with experts and stakeholders.
An in-depth research paper explains why surprise medical bills arise and what policymakers, especially state policymakers, can do to address the problem.
Experts examine several key recommendations for implementing the No Surprises Act, including questions related to the arbitration process and the agencies’ options for resolving those issues.
In 2018 New Jersey implemented a final-offer arbitration system to resolve payment disputes between insurers and out-of-network providers over surprise medical bills.
This analysis of newly released data from the New York Department of Financial Services shows that the state's arbitration process for surprise out-of-network bills is substantially increasing what New Yorkers pay for health care.
Rep. Ruiz’s arbitration proposal for surprise billing (H.R. 3502) would lead to much higher costs and deficits
Rep. Ruiz and a bipartisan group in the House have introduced a problematic arbitration-based bill, which is likely to drive up health care costs.
Read our submitted comments to the Senate HELP Committee on the Lower Health Care Costs Act of 2019, which included three alternative surprise billing proposals.
The “Network Matching” approach offered by the U.S. Senate HELP Committee is one of the best proposals at the federal level.
Bipartisan Senate legislation (from Senators Bennet, Brown, Carper, Cassidy, Cramer, Grassley, Hassan, Murkowski, Sullivan, and Young) includes an arbitration feature that has limited upside.
The No More Surprise Medical Bills Act of 2018 from Senator Hassan was one of the earliest proposals.
Read an analysis of federal actions that can lessen the risk or mitigate the impact of surprise medical bills for insured Americans.
Experts outline ways in which the Department of Labor can help regulate and end surprise medical bills.
Alleged constitutional concerns about surprise billing are not well-grounded.
A scholar provides testimony before the Education and Labor Committee of the U.S. House of Representatives.
Protecting patients from surprise medical bills
Check out our event that took place on October 13, 2016. We brought together representatives from health systems, insurers, and consumer advocacy groups, as well as policymakers and experts, to discuss solutions to comprehensively reduce surprise billing scenarios and resolve disputes over reimbursement for out-of-network care.