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

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

It's all part of the health care reform bill that includes surprise medical billing legislation being crafted in the Senate.

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

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

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

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

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

And who's paying for those negotiations? That's where employers need to pay attention. "Arbitration is going to be clunky and consuming, but theoretically your third-party administrator will add services to facilitate that on your behalf, though likely not for free," Conley said.

Beyond an end to balance billing, perhaps the most exciting possible reform in the bill for consumers is an accelerated timeline for medical billing. "As things exist today, you get a meaningless bill from the provider that says this hasn't been submitted to providers, and then months later you get a statement of what you actually owe," Conley said.

Under the new regulations, the provider would have 20 days from the time of service to submit a bill to the health plan, which would in turn have 20 days to review the bill and apply their share of payments. Then, the provider would have 20 days to send a final bill to the patient.

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

There's also a significant section on Pharmacy Benefit Management (PBM) reform, a hot topic in the fight to bring down high drug prices. "The DOL has been looking at this for a long time," Conley said. "This would require periodic reports to be submitted to plan sponsors, and all rebates passed through to plans. This has the potential to significantly simplify what has historically been a pretty convoluted space."

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

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

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

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

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A few more details in the latest surprise billing legislation

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