“Surprise billing” occurs when a patient unknowingly receives care from a provider outside of their insurance network and the provider subsequently bills the patient for the amount not covered by their insurer. As many states have acted to hold patients harmless – which means that the patient is not liable for the billed amount – Congress continues to debate the best approach to resolve this issue for federally regulated insurance markets.

The key sticking point for Congress is resolving how providers should be paid when patients are no longer held responsible. Stakeholders and Congress are largely divided between two different approaches: benchmark rates vs. arbitration. Benchmark rates refers to the solution where an out-of-network provider would be paid based on in-network rates. Arbitration refers the solution where an independent third-party would consider information provided by the insurer and provider and then determine an appropriate payment rate due to the provider.

On Sept. 17^th and 18^th URAC met with ten Congressional offices to discuss how accreditation improves quality and can be a valuable tool for whatever solution Congress adopts to address surprise billing.

URAC does not take an official position on the benchmark vs. arbitration debate; the position that we conveyed to Congress is that patients should be removed from the middle and accreditation should be considered as a useful quality tool for policymakers when crafting a solution. While we did speak about the potential role for accredited independent review organizations (IROs) in an arbitration model, we also were able to highlight our much broader range of programs and discuss our role as the accreditor for external review organizations as required by the ACA. Our engagement with these key Congressional offices raised our profile, as many staff were unaware of the broad and important role URAC plays in assuring quality in our delivery system.

The National Association of Independent Review Organizations (NAIRO) also joined us for our meetings last week.  Since they represent URAC-accredited organizations currently serving as arbiters in states that have already adopted this model, together we were able to educate staff and address many questions about accreditation, the external review process established in the ACA, and how the arbitration model functions in New York.

Below is a list of the offices we’ve had formal, in-person meetings with to date:

1. Sen. Alexander (R-TN)/Majority Health, Education, Labor and Pensions (HELP) Committee Staff
2. Sen. Murray (D-WA)/Minority HELP Committee Staff
3. Sen. Casey (D-PA)
4. Sen. Toomey (R-PA)
5. Sen. Cornyn (R-TX)
6. Sen. Cruz (R-TX)
7. Sen. Cassidy (R-LA)
8. Sen. Hassan (D-NH)
9. Rep. Neal (D-MA-01)
10. Rep. Doggett (D-TX-35)
11. Rep. Brady (R-TX-08)
12. Rep. Engel (D-NY-16)

We believe this was an important and successful step in our ongoing efforts to build relationships with key policymakers on the Hill and elevate our national profile as an independent expert on health care quality.

As Congress continues to consider a solution to surprise billing, we will keep working to promote the role of URAC and accreditation in whatever solution is adopted.

And as always, please feel free to contact myself or Brittany should you have any questions or wish to discuss anything!