Shock Medical Payments Price Individuals Hundreds of thousands. Congress Is Lastly Set to Ban Most of Them.

Hospitals and doctors, who tend to benefit from the current system, struggled to defeat solutions that would lower their pay. Insurance companies and large insurance groups, on the other hand, wanted a stronger way to negotiate lower payments to the types of medical providers that can currently send surprise bills to patients.

The legislation nearly passed last December but was sunk in the eleventh hour after healthcare providers aggressively opposed the deal. Private equity firms, which own many of the medical providers that deliver surprise invoices, have put tens of millions in advertisements opposed to the plan. The committee chairs argued over jurisdictional issues and postponed the matter.

This year, many of the same lawmakers who were behind last year’s failed efforts tried again, mitigating several provisions most uncomfortable for influential lobbies of doctors and hospitals. The current version is unlikely to do as much in reducing healthcare spending as the previous version, but will still protect patients.

After years of defeat, consumer interest groups welcomed the new legislation.

“This was a real win over money for Americans,” said Frederick Isasi, executive director of Families USA. “The real point here was for Congress to recognize in a bipartisan way the profanity of families who paid insurance and were still firing financial bombs.”

The final compromise would require insurers and medical providers unable to agree on a payment rate to use an outside arbitrator to make a decision. The arbitrator would determine a reasonable amount, depending in part on what other doctors and hospitals typically pay for similar services. Patients could be charged for the type of co-payment they would pay for in-network services, but no more.

This type of policy is generally seen as more beneficial to healthcare providers than the other proposal considered by Congress, which would have minimized the role of arbitrators and instead set benchmark reimbursement rates. Several states have established their own arbitration procedures and have found that most price disputes are negotiated before an arbitrator is involved.

“If this bill forces them to come to the table and negotiate a solution, it will be a clear win for everyone,” said Christopher Garmon, assistant professor of health administration at the University of Missouri, Kansas City, who outlines the scope of the problem.

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