ALERT: Proposed Legislation on Surprise Medical Bills and Balance Billing

There has been a lot of talk about “Surprise Medical Bills” and “Balance Billing” in the news over the last few years. While the matter is a broader health care delivery issue, there has been a great deal of consternation about the impact of balanced billing for medical transport services on patients. The medical transport industry is at the center of this controversy.

ALERT: Proposed Legislation On Surprise Medical Bills And Balance Billing

The Proposed Compromise Legislation

The House and Senate leaders have reached a compromise on balanced billing legislation. The proposed legislation is called the “No Surprise Act” and is receiving bipartisan, bicameral support. The compromise version of the Act includes language that will impact air and ground medical transport suppliers.

The Act would prohibit the balance billing of patients, provides a no-threshold arbitration process, and includes data collection language on industry costs and claims. However, the bill also adds several new elements to the arbitration process, such as the consideration of the median-in-network rate. The Act would require the arbitration process to consider aspects of training and quality of the supplier as well as the vehicle used to transport the patient. While these are important factors to consider in payment, remember there are no nationally recognized data metrics on which to consider these factors.

Main Provisions

The following is a summary of the main areas addressed in the compromise that is currently under consideration:

Patient Protection

The Act holds patients harmless from surprise medical bills, including from air ambulance suppliers, by ensuring they are only responsible for their in-network cost-sharing amounts. This provision applies to deductibles, in both emergency situations and certain non-emergency situations, where patients do not have the ability to choose an in-network supplier. This provision would limit the financial responsibility for patients.

Balanced Billing Prohibitions

The Act prohibits certain out-of-network suppliers from balance billing patients unless the supplier gives the patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care. This provision would almost certainly eliminate balance billing in emergency situations.

Dispute Resolution

The Act creates a framework that takes patients out of the middle and allows health care suppliers and insurers to resolve payment disputes without involving the patient. Under the current terms, insurers will make a payment to the supplier that is determined either through negotiation between the parties or an Independent Dispute Resolution (IDR) process. There is no minimum payment threshold to enter IDR, and claims may be batched together to ease administrative burdens.

Independent Dispute Resolutions (IDR) Provisions

If the parties choose to utilize the IDR process, both parties would submit an offer to the arbiter. The arbiter must be an independent entity with no affiliation to suppliers and/or payors. When choosing between the two offers the arbiter is required to consider the median in-network rate, information related to the training and experience of the supplier, the market share of the parties, previous contracting history between the parties, complexity of the services provided, and any other information submitted by the parties. Following an IDR process, the party that initiated the dispute may not take the same party to arbitration for the same item or service for 90-days following a determination by the arbitrator. However, all claims that occur during the 90-day period are eligible for IDR after the 90-days.

Additional Consumer Protections

The Act provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers. It also empowers consumers by providing a true and honest cost estimate that describes which suppliers will deliver their treatment, the cost of services, and supplier network status.

Advisory Committee for Air Ambulance Billing

The Act requires the Secretaries of Labor, HHS, and Treasury to establish an advisory committee for reviewing options to improve disclosure of charges and fees for air ambulance services, inform consumers of insurance options for such services, and protect consumers from balance billing. The Act requires air ambulance suppliers to submit two years of cost data to the Secretaries of HHS and Transportation and insurers to submit two years of claims data related to air ambulance services to the Secretary of HHS. The Act requires the Secretaries to publish a comprehensive report on the cost and claims data submitted. This provision begins the cost data recording process that is already in place for ground suppliers.

Advisory Committee for Ground Ambulance Billing

The Act requires the Secretaries of Labor, HHS, and Treasury to establish an advisory committee for reviewing options to improve disclosure of charges and fees for ground ambulance services, inform consumers of insurance options for such services, and protect consumers from balance billing. The current draft requires a report on recommendations from the committee not later than 180 days after first meeting.

Looking Forward

These are unprecedented times, and one thing is for certain, healthcare delivery systems will never be the same as they were prior to the COVID-19 Pandemic. However, the issue of Surprise Medical Bills and Balance Billing remains an illness without a cure or a vaccine. The Act is a treatment for the symptoms.

Prospects for Passage

Many of the rub points in the various solutions that have been presented revolve around the economic considerations for each of the constituent groups. Getting to a fair and equitable reimbursement will certainly be the key to eliminating the need for Balance Bills and should drive suppliers toward in-network status. The broad support in Congress indicates a willingness to proceed. Of course, health care insurance and supplier groups have some concern about the current provisions. All indications are that this legislation is a priority.

Regulatory Process

Once passed, the next step is to develop proposed regulations that will guide implementation of the law. While the Act has some specific tasks/expectations, there are several provisions that will require further input to flush out specific tasks and direction. There are specific areas that are likely to generate more industry comments than others.


The momentum for the Act appears to be growing. Passage is anticipated before Inauguration Day. The timeline for the rulemaking process is typically 6 to 12 months. The process can be expedited when there are more urgent needs being addressed. The recent COVID 19 related legislation is a great example. The No Surprise Act does have certain hard deadlines built in:

        • Health Plan Adverse Determination Report 1/1/22
        • Dispute Resolution Process 1/1/22
        • HHS, FTC, AG Report 1/1/23

The actual timeline is difficult to predict. Provisions such as the IDR process and cost data collection may spur additional comment and intervention.


The advancement of this legislation, along with many other initiatives, make it clear that the Balanced Billing challenge must be addressed. Major health care delivery constituents are engaged, and some reasonable solution is NECESSARY. The medical transport community has been active in advocating for a solution set that is meaningful, and likely to address the underlying causes and do so without creating a crisis for the industry.

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