No Surprises “Balance Billing” Act

Congress has bipartisan support on stopping or limiting surprise medical billing if a patient receives care from a non-network provider that provider will “balance bill” the patient which create surprise medical billing. 

Balance billing is happening all over the country, including Indiana.  The patient usually in an emergency receive medical services from a provider that is not participating in their insurance network. A common situation is central Indiana is that the emergency room doctors are not participating in the network, but the facility is.  About 30 days after services have been received, the patient may receive a bill from a medical provider they don’t recognize. Then after some frustrating research, they learn those doctors are not in network and can charge whatever they feel is reasonable.

With Health Maintenance organization (HMO) & Employers provided organization (EPO) we are seeing more and more plan that offers no coverage for out of network claims.   Even PPO’s are starting to have gaps in coverage where the medical provider and the insurance company cannot agree on medical reimbursement rates. 

The stakeholders in this debate are the medical community and health insurance carriers. Each side is point fingers to blame the other.


The No Surprise Act would set medical rates at 100% of the current median in-network reimbursement rates.  Which would still lead to patients having surprise medical bills but would give a patient a level of protection on what the medical provider could charge. 

If each community starts using an average cost for all medical services, we could see the insurance companies’ proprietary networks become less valuable.  This would have a significant impact on the health insurance industry.  If the medical community is held to a fixed priced for the procedure they perform, this could impact the large medical groups. 

It will be fascinating to see the final bill’s impact on both stakeholders.

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