Details of the latest surprisebilling legislation are starting to come to light, to thejoy of patients–but maybe not so much employers or health careproviders.

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Imagine it: Before you go to the doctor, you're able to look upthe estimated cost of your procedure online. Then, within twomonths, you get a final bill for the actual services–not anestimate that has yet to be processed by your insurers or aconfusing EOB, but the actual, final total due.

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It would be an amazing win for health care consumers. Andactually, it could be close to reality.

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It's all part of the health care reform bill thatincludes surprise medical billing legislation beingcrafted in the Senate.

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Over the weekend, legislators were able to push past somesticking points in this popular piece of bipartisan legislation,exciting enough news in itself. And now, details about other provisions in the Lower Health Care Costsact are starting to come to light, to the joy ofpatients–but maybe not so much employers or health careproviders.

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Related: Consumers still confused by health care shopping,billing practices

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Though the full text of the legislation has yet to be released,Ben Conley, a partner with law firm Seyfarth Shaw, was able toshare some insider insights in a recent Businessolverwebinar looking at 2020 employer compliance issues. "Thislegislation has a lot," Conley said. "It's a hodgepodge of wishlist items that have accumulated since the ACA. There's going to bea lot of changes to health care administration and pricing if thisdoes pass."

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First, there's the issue that had divided lawmakers trying tohammer out a solution to surprise out-of-network bills: how tosettle on a reimbursement rate?

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According to Conley, the legislation calls for creating twocategories of out-of-network claims: For bills of $750, or less amedian negotiated in-network benchmark rate would be charged basedon area rates, with no room for negotiation or balance billing.

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"If more than $750, those bills would be eligible to besubmitted to arbitration," Conley said. "An independent arbiterwould look at the evidence submitted by both sides and determinewhat would constitute a reasonable rate for those services." (Thesesame rules would apply to balance-billing for air ambulances, butwith a $25,000 price cutoff between billing tiers.)

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And who's paying for those negotiations? That's where employersneed to pay attention. "Arbitration is going to be clunky andconsuming, but theoretically your third-party administrator willadd services to facilitate that on your behalf, though likely notfor free," Conley said.

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Beyond an end to balance billing, perhaps the most excitingpossible reform in the bill for consumers is an acceleratedtimeline for medical billing. "As things exist today, you get ameaningless bill from the provider that says this hasn't beensubmitted to providers, and then months later you get a statementof what you actually owe," Conley said.

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Under the new regulations, the provider would have 20 days fromthe time of service to submit a bill to the health plan, whichwould in turn have 20 days to review the bill and apply their shareof payments. Then, the provider would have 20 days to send a finalbill to the patient.

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So, at most, a patient should receive a final bill within 60days. And if not? "The employee is not required to pay the bill,"Conley said. Yes, you heard that right. If the bill is late, youdon't have to pay.

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There's also a significant section on Pharmacy Benefit Management (PBM) reform, a hottopic in the fight to bring down high drug prices. "The DOL hasbeen looking at this for a long time," Conley said. "This wouldrequire periodic reports to be submitted to plan sponsors, and allrebates passed through to plans. This has the potential tosignificantly simplify what has historically been a prettyconvoluted space."

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Another big one, says Conley: Out-of-pocket costs. "Anothercomponent would require providers and health plans, within two daysof request, to give an estimated out-of-pocket cost of care."

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We're not done yet: there's language in the bill that wouldrequire self-funded plans to begin submitting data to states'all-payer claims databases. Unlike fully fundedplans, self-funded plans have been able to opt out of thisrequirement in the past but would no longer be able to. "We'rehearing there will be a uniform reporting format that would apply,but this is potentially an onerous burden," Conley said.

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Even more details are likely to surface in the coming days,providing employers and their health plan providers with a lot tokeep them busy in the new year, assuming the legislation passes.And Conley thinks there's a good chance of that happening, as bothDemocrats and Republicans are looking to take home a win going intothe election year.

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"This was a bipartisan compromise within the Senate that has thesupport of the administration," Conley said. "It's unlikely theHouse would be unwilling to pass something like this. It seems likethis is a go."

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Emily Payne

Emily Payne is director, content analytics for ALM's Business & Finance Markets and former managing editor for BenefitsPRO. A Wisconsin native, she has spent the past decade writing and editing for various athletic and fitness publications. She holds an English degree and Business certificate from the University of Wisconsin.