By NextBestFitSet a default out-of-network rate instead of arbitration
Pay out-of-network bills at a fixed benchmark (e.g., a percentage of Medicare), ending the independent dispute resolution system.
Interim: ends arbitration costs before networks disappear.
Review ledgerHow this path connects
This path
Set a default out-of-network rate instead of arbitration
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Set out-of-network payment at a fixed percentage of Medicare
- End the independent dispute resolution process
- Include ground ambulances
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Surprise billing and a runaway arbitration system
A fixed benchmark for out-of-network bills replaces costly arbitration in a dispute system flooded with cases. It makes payment predictable for providers and insurers.
What it creates or worsens
- Reduces income or business for affected groups
Provider groups argue that fixed benchmarks reduce their pay.
- Providers leave, retire, or go cash-only if pay drops
Benchmarks set too low weaken emergency and anesthesia staffing.
3 paths soften this
Phase rate changes in over several yearsProviders leave, retire, or go cash-only if pay dropsChosenStrict opt-out rules for cash-only practiceProviders leave, retire, or go cash-only if pay dropsChosenLower costs for clinicians, not only payProviders leave, retire, or go cash-only if pay dropsChosen
Who's affected
Who gains
- People with ongoing or specialist care needs
- Surprise billing and a runaway arbitration system: Ambulance rides and out-of-network specialists send bills patients didn't choose.
- People with employer coverage
- Surprise billing and a runaway arbitration system: Premiums fund the higher arbitration awards.
- Health insurers, brokers, and their shareholders
- Surprise billing and a runaway arbitration system: A fixed benchmark for out-of-network bills replaces costly arbitration in a dispute system flooded with cases. It makes payment predictable for providers and insurers.
- Cash-pay and private care practices
- Providers leave, retire, or go cash-only if pay drops: Payment cuts can shift providers toward cash-only care.
Who loses
- Hospitals and specialist groups with high private prices
- Surprise billing and a runaway arbitration system: Private-equity-backed emergency, anesthesia, and radiology groups win high awards.
- Private equity firms and investors
- Reduces income or business for affected groups: Provider groups argue that fixed benchmarks reduce their pay.
- People with ongoing or specialist care needs
- Providers leave, retire, or go cash-only if pay drops: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.
- Residents of areas with too few health professionals
- Providers leave, retire, or go cash-only if pay drops: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.
Where it has been tried
- Maryland: All-payer hospital rates make surprise hospital bills largely impossible.Sources: CMS Innovation Center / RTI (2023)