May 20, 2019: MGMA letter on unexpected medical bills

May 20, 2019  

The Honorable Lloyd Doggett
Chairman
Committee on Ways and Means 
Subcommittee on Health
2307 Rayburn House Office Building
Washington, DC 20515


The Honorable Devin Nunes
Ranking Member
Committee on Ways and Means 
Subcommittee on Health
1013 Longworth House Office Building
Washington, DC 20515

Dear Chairman Doggett and Ranking Member Nunes:

On behalf of our member medical group practices, healthcare executives, and other healthcare leaders, the Medical Group Management Association (MGMA) is committed to protecting patients from out-of-network medical bills that result from unexpected gaps in coverage and from healthcare costs that their insurance will not cover. MGMA appreciates the opportunity to submit for the record our comments on the hearing “Protecting Patients from Surprise Medical Bills.” We appreciate your leadership on this important matter and look forward to working with you to develop a solution that first and foremost protects patients and their access to care. 

MGMA is the premier association for professionals who lead medical practices. Since 1926, through data, people, insights, and advocacy, MGMA empowers medical group practices to innovate and create meaningful change in healthcare. With a membership of more than 45,000 medical practice administrators, executives, and leaders, MGMA represents more than 12,500 organizations of all sizes, types, structures, and specialties that deliver almost half of the healthcare in the United States. 

As the Subcommittee evaluates potential legislation to provide relief to patients from healthcare costs their insurance will not cover, MGMA developed the following policy framework that we urge you to consider:

• Limit patient financial responsibility. Patients should be protected from the financial impact of unanticipated gaps in insurance coverage when accessing emergency services outside their network and do not have the ability to select such services from an in-network healthcare professional. 
• Protect patients from payment disputes. Health plans should be responsible for paying the out-of-network provider directly so that patients are not burdened with payment rate negotiations. 
• Ensure network adequacy. Overly narrow networks contribute significantly to the problem of unanticipated medical bills; thus, any policy solution should ensure that health plans meet appropriate network adequacy standards, including access to hospital-based physician specialists. 
• Require health plan transparency. Health plans must be transparent and proactive in informing patients about benefits and potential cost obligations. Health plans should also be required to regularly update and verify the accuracy of provider directories.
• Preserve private negotiation. In general, the government should not establish a fixed payment amount for out-of-network services. A fixed payment rate could undermine patient access to in-network care because health plans have less incentive to contract in-network clinicians if they can rely on a default out-of-network payment rate.
• Pursue payment equity. Any out-of-network payment guidelines pursued by policymakers should be based on reasonable physician charges for the same service in the same geographic area from an independently recognized and verified benchmarking database. In situations where the established minimum payment standard is insufficient, an alternative dispute resolution process should be available. Arbiters should not be required to consider in-network or Medicare rates when issuing final determinations on appropriate reimbursement.

View the full letter