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Future Of Surprise Medical Billing Legislation Remains Uncertain


Surprise medical billing was supposed to be the easy health care fix that Washington could get done this year. In May, President Trump urged Congress to come up with a solution.


PRESIDENT DONALD TRUMP: No American mom or dad should lay awake at night worrying about the hidden fees or shocking, unexpected medical bills to come.

SHAPIRO: Bills were introduced and advanced. Democrats, Republicans, senators, House members - practically everyone agreed the practice was bad and it should stop. Now Congress is getting ready to wrap up the year and still hasn't passed legislation. NPR's Selena Simmons-Duffin explains what's going on.

SELENA SIMMONS-DUFFIN, BYLINE: This is an easy thing to get worked up about. It just seems so unfair. The classic scenario is this - you go to an emergency room, even one that's in your insurance company's network. A doctor working there is not in your network and consults with you or treats you. That doctor can bill you what's called a balance bill. So the insurance company tells the doctor, we'll pay $1,000. The doctor says, well, I'm going to charge $5,000, and you are on the hook for that difference.

ERIN FUSE BROWN: There's a lot of agreement that this is a broken part of the health care system that everyone agrees the market can't fix by itself.

SIMMONS-DUFFIN: Erin Fuse Brown is a law professor at Georgia State University. Because so many members of Congress in both parties agree that it's outrageous and a place where the government needs to step in, this seemed doable.

FUSE BROWN: Absolutely doable. It's not fixing the whole health care system.

SIMMONS-DUFFIN: It's like low-hanging fruit.


SIMMONS-DUFFIN: But there are two problems - agreeing on how to get it done and getting passed a flood of lobbying money. Anna Massoglia is a researcher with the Center for Responsive Politics. And she says, at the end of July, a group with the friendly sounding name Doctor Patient Unity came out of nowhere.

ANNA MASSOGLIA: Doctor Patient Unity, practically overnight, spent about $28 million on ads.

SIMMONS-DUFFIN: Ads like this one.


UNIDENTIFIED PERSON: Congress is working to end surprise medical billing, and that's a good thing. But that fix cannot include government rate setting, a slippery slope toward doctor shortages...

SIMMONS-DUFFIN: Massoglia says it was clear this was a front group for industry, but there was very little information about who was funding it. The mystery lasted until September, when the group revealed themselves to reporters at The New York Times. It turns out...

MASSOGLIA: Private equity-backed firms were some of the entities bankrolling the operation.

SIMMONS-DUFFIN: Private equity had been buying up physician groups. Surprise bills were part of their business model to bring in profits for investors, and they jumped in to defend that business model. While social media and TV got bombarded, Dan Auble, who's also from the Center for Responsive Politics, says Congress was getting bombarded, too. Last year, only a few dozen groups lobbied on surprise billing. This year?

DAN AUBLE: We've seen 340 groups mention it on their lobbying reports, and they've hired 1,200 lobbyists to do that work.

SIMMONS-DUFFIN: But the lobbying and ads are not the whole story here. The other big issue is how to fix the surprise billing problem, says Fuse Brown.

FUSE BROWN: The disagreement really comes down to how to determine the amount that the health insurance company is going to pay the out-of-network provider.

SIMMONS-DUFFIN: So remember - if the doctor wants to charge $5,000 and the insurer wants to pay $1,000, how do you settle on the amount?

FUSE BROWN: There's this hot debate about where do you set the payment amount and what role does the government have in actually setting it or does it just sort of set up a mechanism for some third party to decide?

SIMMONS-DUFFIN: There are bipartisan bills in the House and the Senate. There was momentum in the summer. In the fall, things seemed stalled. But congressional meetings are starting up again. So now the state of play is this - the White House and lawmakers mostly say they're optimistic this can get done by Christmas. But there are still hurdles to clear. So even this low-hanging health policy fruit might not get picked this year.

Selena Simmons-Duffin, NPR News.

(SOUNDBITE OF JELLIS AND SUBSET'S "KYOTO") Transcript provided by NPR, Copyright NPR.

Selena Simmons-Duffin reports on health policy for NPR.
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