| The fight over how insurers and providers settle surprise medical bills is heating up on Capitol Hill, with House lawmakers pursuing competing fixes to the No Surprises Act, the law meant to protect people from unexpected out-of-network medical bills. Rep. Frank Pallone Jr. (New Jersey), the top Democrat on the House Energy and Commerce Committee, introduced legislation Thursday that would scrap the law’s current arbitration system, and instead set up payments based on the median in-network rate for the same service. The bill would also require insurers to pay providers within 30 days. - The benchmark: Beginning in 2028, the benchmark payment rate would be based on the median rate an insurer had negotiated for the same or similar service in the same region and medical specialty as of 2019, and adjusted for inflation through 2027. Starting in 2029, that benchmark would increase each year based on inflation.
Pallone, one of the original authors of the surprise-billing law, has long backed a benchmark approach. He argues that the current arbitration system has created incentives for providers — particularly, he says, private equity-backed groups — to seek inflated payments. Democrats appear likely to regain control of the House following November’s midterms, which could give Pallone additional leverage in working out a fix. Why it matters: The No Surprises Act succeeded at its central goal of taking patients out of payment disputes. But the fight has shifted to what happens after that — and insurers, employers and consumer groups are arguing that some excessive arbitration awards will end up raising premiums for everyone. Meanwhile, providers say insurers aren’t paying promptly or fairly. Pallone appeared on CBS Mornings on Wednesday to discuss the issue, and previewed that legislation would be coming. Punchbowl first reported the details of the bill Thursday morning. “Anesthesiologists, radiologists [and] emergency doctors are increasingly owned by private equity, and private equity is … driving up this arbitration process,” Pallone told CBS in the segment. The private equity industry, Pallone said, “insisted on this arbitration process [being in the original bill]. I knew it was not going to go well, but I didn’t know it was going to be this bad.” - It drew immediate praise from consumer groups such as Families USA, which recently put out a report proposing an overhaul of the system that aligns with the Pallone bill.
The newly proposed legislation “would take away the incentive for corporate middlemen to flood the system with disputes and win inflated payouts,” said Anthony Wright, the organization’s executive director. Families USA led a coalition of 66 groups on a letter last month that called for Congress to address the rising costs of the dispute-resolution system. - On the other side of the ideological spectrum, the conservative Paragon Health Institute last month issued a report advocating for the elimination of the arbitration system for elective health services and using the most up-to-date, median in-network rates to settle disputes — rather than adjusting 2019 benchmark rates for inflation, as Pallone’s bill does.
TeamHealth, a for-profit emergency room staffing company that is often shown to be a top initiator of the arbitration system, supported parts of the legislation focused on timely payments, but is skeptical of basing the payment rates on amounts set by insurance companies. - “Eliminating independent arbitration and relying on insurer-calculated, median in-network rates would risk access to emergency care for those who need it and increase insurer profits,” Josh Hopson, TeamHealth’s vice president of integrated marketing and communications, tells me.
When the initial law was coming together, the company helped fund a multimillion-dollar campaign against using benchmark rates, instead favoring arbitration. “TeamHealth uses arbitration in good faith when insurers are unwilling to negotiate reasonable agreements or fail to appropriately reimburse out-of-network care. We believe Congress should improve on the No Surprises Act by focusing on targeted reforms that improve efficiency, transparency and accountability,” Hopson said. - The competing approach: The House Ways and Means Committee has been working on its own package that keeps the law’s independent dispute-resolution system in place. That proposal is expected to pair legislation from Rep. Greg Murphy (R-North Carolina) penalizing insurers that miss payment deadlines with provisions aimed at preventing providers from submitting ineligible claims.
The committee did not respond to an inquiry asking about its legislative timeline. But the disputes over the scope of any overhaul of the law will likely push the issue into the next Congress. The Trump administration is weighing a temporary reprieve for certain restricted peptides, potentially giving compounding pharmacies a way to sell the products while federal officials work on longer-term rules, according to an exclusive from The Post’s Rachel Roubein. The plan would ease the path to market for some peptides promoted for wellness and medical uses, even though their safety and effectiveness remains murky. The proposal is still in development, and officials are working on safeguards, according to two people familiar with the discussions who spoke with Rachel on the condition of anonymity to share private details. Why it matters: Proponents argue the move could bring parts of the booming peptide market into a more regulated setting. But it would also put the administration at odds with Food and Drug Administration scientists who have warned that the evidence doesn’t support broader access. Scott Brunner, CEO of the Alliance for Pharmacy Compounding, said his group has met with the FDA and urged regulators to temporarily exercise enforcement discretion, which could allow state-licensed pharmacies to compound certain peptides for patients with prescriptions. The proposed approach would include enhanced disclosures to patients, reporting of serious adverse events and data collection about peptide use, Brunner said. He argued that bringing some activity under pharmacy oversight would be preferable to leaving consumers to turn to illicit sellers. It’s not yet clear which specific peptides are under consideration, Rachel reports. But the FDA has been weighing whether to allow compounding pharmacies to make seven peptides marketed for uses ranging from insomnia to obesity and wound healing. The Department of Health and Human Services did not comment. Career scientists at the FDA concluded in June that the available evidence was inadequate to establish the products’ safety and effectiveness. But, the following month, a federal advisory committee recommended easing restrictions on six of the seven peptides. Several members had connections to peptide sellers or promoters, and FDA officials had expressed concern about appointing people with those ties to the federal panel that’s reviewing a handful of those products. Meanwhile, the Campaign Legal Center wrote a letter to the HHS inspector general in August, asking the office to investigate whether seven members of the FDA’s advisory panel violated federal ethics laws. Read the full story: “Trump administration paving way for temporary sale of some unapproved peptides.” The Trump Administration’s review of mifepristone will stretch into next year, putting off any potential changes to the abortion pill’s restrictions until after the midterms. The FDA said in a court filing on Wednesday it expects to have results from its safety study by mid-December, and to complete its analysis and final report by March. The agency said its study feasibility work is complete and that the agency has determined it has enough data and outcomes to conduct the analysis. → It’s part of the lawsuit filed by the state of Louisiana, arguing the agency should reverse a pandemic-era decision to allow mifepristone to be prescribed via telehealth and delivered by mail. The agency is studying the safety of mifepristone, used with misoprostol through 70 days of pregnancy. Medication abortions represent more than 60 percent of abortions in the U.S. health system, according to the Guttmacher Institute. The drugs have been shown to be safe and effective after decades of review. Why it matters: The timeline falls short of what antiabortion groups have been pressing the Trump administration to do, and signals that regulators will not restore restrictions on access that were loosened during the Biden administration before the review ends. Last month, a coalition of 50 pro-life leaders called on FDA Commissioner nominee Heidi Overton to, if confirmed, immediately restore the in-person dispensing requirement and end mail-order distribution while the safety study is ongoing. The FDA’s filing instead indicates that the current rules will remain in place during the review absent separate agency action. The Supreme Court in May allowed telehealth prescribing, pharmacy dispensing and mailing of mifepristone to continue while the litigation proceeds. Separately, the agency says it is reviewing the restrictions on mifepristone, including poring over hundreds of public comments and petitions calling for some of the rules to be restored. Two other court rulings require the FDA to take another look at certain restrictions implemented alongside the loosening of the rules in 2023 and explain why they’re necessary. “Trump emails Medicare enrollees about $90 payment, touts his policies,” The Post’s Dan Diamond and Isaac Arnsdorf report. “CDC Is Moving Forward With a Previously Shelved Controversial Hepatitis B Vaccine Study,” Katherine Eban reports at Rolling Stone. “MAHA loyalists accuse Trump administration of ‘broken promises,’” Julie Tsirkin and Aria Bendix report at NBC News. “Trump Wrongfully Withheld Health Research Funds, Watchdog Finds,” Sandhya Raman reports at Bloomberg Law.
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