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ACEP4U: Out of Network Billing (Surprise Billing)

ACEP is working to protect emergency medicine and your patients. Surprise billing (also known as out-of-network billing) is the most important issue facing emergency physicians today. The decisions being made in Washington, D.C., could have a far greater impact on how we care for our patients than even EMTALA did in 1986.

For more than a year, surprise billing has been a central focus of ACEP’s federal advocacy efforts, building on years of state-level advocacy already done on this issue. Much of this conflict over surprise billing is playing out in the media, and insurers have been trying their hardest to paint emergency physicians in a bad light. Our public relations team is working diligently to make sure the physician side of the story is fairly portrayed both in the press and in Congress. 

Want to take action and ensure your voice is heard? Check out our advocacy toolkit, or send emails to your members of Congress -- in just a few clicks, you can personalize and send a prepopulated email advocating for emergency medicine in this important debate. 

What's Happening on Capitol Hill?

If you are employed by a small or large staffing group, which the majority of ACEP members are, this legislation could impact how you are reimbursed for the care you provide out-of-network patients – either directly or indirectly. To learn more about how you can advocate to protect emergency medicine on this issue, please visit our ACEP member advocacy toolkit.

Congress is debating various proposals,  but here’s what you need to know:

  • If the legislation uses a “benchmark” to cap rates for out-of-network emergency care, then even future in-network rates will likely decrease over time, since that out-of-network cap will impact future contracting dynamics between insurers and physician groups.
  • Instead of these approaches, ACEP is advocating for legislation that would implement a "baseball-style" arbitration process to settle billing disputes between insurers and physicians such as the systems used in New York, which passed its own surprise billing legislation in 2014.

ACEP Advocacy Efforts: A Timeline
Here’s an overview of our advocacy timeline so you can see where we started, what’s happening now and where we are heading next.



September 5: ACEP coordinates and sends a letter to key committees in Congress that is signed by 60 smaller emergency physician groups to bring attention to the disproportionate impact that certain proposals being considered by Congress would have on small groups. 

September 4: ACEP, the AMA, and 8 other hospital-based specialties send a letter to the House Education & Labor, and Ways & Means Committees outlining key priniciples that should be included in their respective surprise billing proposals under development. 


Congress is in recess but the advocacy continues. Visit our August recess member advocacy toolkit to learn how to contact your federal legislators and their staff while they are at home for the recess period. This will ensure that when Congress returns to the surprise billing issue in September, lawmakers will be fully aware of the potential impact on EM. 

JULY 2019

July 17: ACEP issued a statement in response to the Energy and Commerce Committee markup supporting the markup's amendment to include independent dispute resolution while stating that the qualifying threshold for IDR needed to be lowered.

JUNE 2019

June 26: The Senate HELP Committee passes the Lower Health Costs Act, despite significant opposition from the provider community, including ACEP. Read the letter here stating strong concern with the bill's approach capping payment for out-of-network emergency care at the insurer's median in-network rate for that geographic area. 

June 26: ACEP supports the "Protecting People From Surprise Medical Bills Act" because it "truly takes patients out of the middle of disputes between insurers and medical providers. This bill goes further than any other legislative proposals to encourage transparency from insurance providers and make sure that patients understand the limitations of their insurance." Read the ACEP release.

June 10: ACEP President Vidor Friedman, MD, FACEP, testifies on behalf of emergency medicine before the House Energy & Commerce Health Subcommittee in its hearing on surprise billing. Watch it here, or read his written testimony.  

June 5: ACEP responds with a detailed comment letter to the legislative discussion draft, the Lower Health Costs Act, released by the Senate HELP Committee, which contains a section on surprise billing. The surprise billing policy options offered in the draft would dramatically disrupt the health care system and significantly distort negotiations between insurers and emergency physicians.

MAY 2019

May 7: More than 550 ACEP members representing 47 states traveled to Washington, DC, for ACEP’s Leadership & Advocacy Conference. They conducted meetings with legislative offices about issues important to emergency medicine, including surprise billing. Shortly after LAC, President Trump gave a statement outlining the White House principles for surprise billing. We issued a statement of response explaining that “the principles the White House laid out do not go far enough to protect patients.” 

May 9: In response to the release of the White House's principles regarding surprise billing, ACEP President Dr. Vidor Friedman said "ACEP shares the Administration's view that improving transparency is critical to stopping surprise bills ... Still, the principles the White House laid out do not go far enough to protect patients."

May 14: The House Energy and Commerce Committee released a discussion draft of legislation on surprise billing for public comment that caps out-of-network payment for emergency care at the median in-network amount. ACEP responded with a comment letter expressing concern and offering recommendations for improvements.

May 17: ACEP responded to the STOP Surprise Medical Bills Act of 2019 introduced by several senators including Sen. Bill Cassidy, MD (R-LA) saying it would tilt a proposed arbitration process in the insurer’s favor.

May 23: ACEP applauded the bipartisan coalition led by emergency physician Rep. Raul Ruiz, MD (D-CA) and Rep. Phil Roe, MD (R-TN) that released its framework for the Protecting People from Surprise Medical Bills Act. 

APRIL 2019

ACEP submitted a statement for the record explaining the perspective of emergency medicine during the House Education and Labor Health Subcommittee hearing regarding surprise medical bills (no provider groups were represented at this hearing). 

MARCH 2019

Tony Cirillo, MD, FACEP, a member of the ACEP Board of Directors, represented ACEP during a surprise medical billing event sponsored by the Brookings Institute. Dr. Cirillo talked about the individual responsibility of all stakeholders—hospitals, physicians, and insurers—to make sure that patients are kept out of the middle when emergency care is out-of-network, and he emphasized our proposed arbitration approach as a way to determine fair reimbursement amounts for out-of-network services.

ACEP continued to meet with Congressional offices to educate them on our framework and the unique aspects of emergency care, including EMTALA.


Feb. 4: ACEP worked with other medical organizations, such as the AMA, ACS, ASA, ACR, and AANS to identify potential areas of agreement that were shared in a group letter to Members of Congress.

Feb. 5: ACEP developed an extensive response to a letter from the Cassidy Workgroup sent to both plans and provider groups, including ACEP, with a detailed list of questions and requests to submit data to help inform their ongoing efforts to develop surprise billing legislation.

Feb. 19: ACEP staff, in conjunction with representatives from the AMA, ASA, ACS, ACP, ACR, CAP, met with the majority and minority staff of the Sen. HELP Committee for a briefing and discussion about surprise billing legislation. In addition, ACEP staff and our consultants continue to meet with all the members of the Sen. HELP Committee, House Energy and Commerce Committee, and Hs. Ways and Means Committee.

Feb. 26-27: ACEP President Vidor Friedman, MD, FACEP, met with several lawmakers who will be instrumental in the development of any surprise billing legislation, including Sen. HELP Committee Chairman Lamar Alexander (R-TN); HELP Committee Ranking Member Sen. Patty Murray (D-WA); HELP Committee members Sens. Maggie Hassan (D-NH) and Johnny Isakson (R-GA); House Energy and Commerce Health Subcommittee Ranking Member Rep. Mike Burgess (R-TX); Rep. Darren Soto (D-FL); as well as staff for the HELP Committee, Hs. Minority Leader Kevin McCarthy (R-CA), and Sen. Bill Cassidy.


ACEP President Vidor Friedman, MD, FACEP, and ACEP Executive Director Dean Wilkerson met with legislators on Capitol Hill to address ongoing discussions on out-of-network billing and other issues critical to emergency medicine, including drug shortages and access to emergency care. Dr. Friedman met with Sen. Bill Cassidy of Louisiana, Rep. Raul Ruiz, MD, of California, and Rep. Richard Hudson of North Carolina, to share ACEP’s message. Dr. Friedman and Mr. Wilkerson also spoke with Representatives Kenny Marchant (R-TX), Brett Guthrie (R-KY), Gus Bilirakis (R-FL), Andy Barr (R-KY), and Bill Flores (R-TX).

Jan. 23: President Trump hosted a roundtable at the White House featuring patients impacted by surprise medical bills and vowed to take action on the issue.

Jan. 28: ACEP released its Framework for Protecting Emergency Patients When Care is Out of Network. This proactive, legislative proposal would take patients completely out of the middle and would implement a baseball-style arbitration approach to settle disputes between insurers and physician groups on out-of-network bills, similar to the NY bill that has proven successful since its implementation. 

Jan. 31: Laura Wooster, ACEP Associate Executive Director for Public Affairs, participated as a panelist for a briefing hosted by the Senate Health, Education, Labor, and Pensions Committee staff, to present and answer questions from HELP Committee staff about surprise billing issues. HELP Committee Chairman Lamar Alexander (R-TN) had indicated that price transparency, including surprise billing, will be a legacy issue for him during his final two years in office. Ms. Wooster shared ACEP’s recently announced framework for protecting emergency patients with the group.

OCT/NOV 2018

We continued our efforts to educate members of the Cassidy Workgroup. Dr. Cirillo and Laura Wooster, ACEP Associate Executive Director for Public Affairs, participated in the Cassidy Workgroup’s meeting with select providers, insurers, consumer groups, researchers, and FAIR Health. A significant portion of this meeting was spent delving further into aspects of arbitration (ACEP’s preferred approach), with considerable pushback from the insurers at the meeting.

In addition to the bipartisan workgroup’s efforts on surprise billing, two other related bills were introduced in the Senate (S. 3541/S. 3592) by Sens. Jeanne Shaheen (D-NH) and Maggie Hassan (D-NH), respectively, that would ban balance billing and provide options to states for how to set reimbursement rate (S. 3541) and establish arbitration for disputed reimbursements (S. 3592).

ACEP continued to work with other medical organizations, such as the AMA, ACS, ASA, ACR, and AANS to identify potential areas of agreement to share with Members of Congress.


ACEP worked with Congressional offices, including Sen. Cassidy, to create a bipartisan agreement on policy that would establish financial protections for patients who received unanticipated emergency care. As this was happening, the Cassidy Workgroup released a draft of legislation that would ban balance billing and – contrary to ACEP’s position – cap payments for out-of-network emergency care at only 125 percent of in-network, contracted rates. ACEP weighed in on the draft with comments.

JULY 2018

ACEP participated in a roundtable discussion on health care price transparency initiated by the Cassidy Workgroup that included the AMA, the American College of Surgeons, the American Hospital Association, insurers and brokers, and patient advocates. This discussion was indicative of an increasing interest from Congress to identify ways to help consumers better understand their cost-sharing obligations before receiving treatment.


Senate bipartisan price transparency workgroup (Senators Bill Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO) – aka the Cassidy Workgroup – solicited input from stakeholders on ways to “increase health care price and information transparency to empower patients, improve the quality of health care, and lower health care costs.” ACEP submitted comments urging them to consider the unique aspects of emergency medicine, explaining how EMTALA and the Affordable Care Act “have had the effect of increasing overall volume, while discouraging incentives for health plans to enter into fair and reasonable contracts to provide services at reasonable in-network rates.”

Stay Updated
ACEP is dedicated to giving emergency physicians a strong and unified voice in Washington, speaking out on the issues that matter most to you and your patients. Want to stay apprised of ACEP’s ongoing federal legislative activities? Sign up for the 911 Legislative Network, the premier grassroots network for emergency physicians. Find continual updates about all of ACEP’s advocacy work – surprise billing and beyond – on the Federal Advocacy page. 


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