EP307: The Surprise Billing Legislation: Its Impact on Providers, Hospitals, Self-insured Employers, and (Most of All) Patients, With Loren Adler

In Episode 307, Stacey Richter talks with Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, about the surprise billing legislation taking effect 1/1/22 — and what it means for providers, hospitals, self-insured employers, and patients.

WHAT YOU'LL LEARN

✅ How the new surprise billing law removes patients from the fight entirely, leaving them to pay only their normal co-pay or coinsurance

✅ How "baseball arbitration" resolves disputes between providers and insurers when they can't agree on a rate

✅ Why providers can't trigger arbitration more than once every 90 days for the same service

✅ How outlawing surprise bills could accelerate the shift toward bundled payments

✅ Why self-insured employer premiums are expected to drop about 1% as a result

WHY THIS MATTERS

Starting 1/1/22, patients are taken out of the surprise billing fight: if a provider sends a bill above what's in network, the patient still pays only their normal cost sharing, while the provider and insurer settle the rest through negotiation or baseball-style arbitration. Loren Adler unpacks who wins and who loses, why this could nudge the industry toward bundled payments and even single hospital bills, and why ground ambulances were left out of the legislation entirely.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:04 What is this surprise billing legislation?

04:27 What happens when a patient is sent a huge bill from the provider?

06:15 What is "the going rate"?

09:44 "If you weren't leveraging surprise billing beforehand, this law has no effect on you."

11:14 Will this legislation push the industry toward one hospital bill?

12:20 What will providers have to do if they don't like what insurance wants to pay them?

15:26 What is benchmark pricing?

17:37 "Fundamentally … it's really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other."

18:19 Is this surprise billing legislation a compromise?

19:48 "Arbitration really isn't meant to adjudicate every single claim."

20:11 "The idea is really to kind of push the facility … to negotiate and figure this all out."

20:50 Are hospitals being impacted by this bill?

24:56 What happens to providers who decide to send surprise bills anyway?

26:09 What are the implications of this legislation for self-insured employers?

28:48 Why have ground ambulances been left out of this surprise billing legislation?

32:23 "At the end of the day, I think this is a net positive for consumers and should be considered a win."