Surprise Billing Fight Splits Into Two Paths as Congress Weighs Pallone Overhaul Against Doctor-Backed Enforcement Bill

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Frank Pallone, D-N.J., would end arbitration and pay out-of-network doctors a benchmark based on median in-network rates, while a doctor-backed bipartisan bill would keep arbitration and penalize insurers that fail to pay awards on time.

The split matters for patients’ wallets even though the 2020 law already shields most people from surprise bills. Arbitration awards are paid by insurers, and those costs can flow into the premiums employers and workers pay each year.

With federal funding set to expire Dec. 11, a year-end spending package could carry a narrower fix, Medical Economics reported.

When an out-of-network doctor treats a patient in an emergency or at an in-network hospital, the patient pays only in-network cost sharing. The insurer and provider then settle the rest, and if they cannot agree, an arbitrator picks one side’s final offer, according to a Congressional Research Service overview.

The timeline is long. Using CMS guidance, CRS estimates that an insurer pays or denies a claim around day 30, open negotiation runs to about day 71, arbitration can begin around day 116, and payment is due around day 202.

More than 4.7 million disputes were filed from 2023 through 2025, and providers won 85.7% of them, CRS found. According to Pallone’s office, providers were awarded nearly $15 billion in 2025, arbitration firms collected $1.3 billion in fees, and about 67% of 2025 disputes came from 10 provider groups, which Pallone says are mostly backed by private equity.

Pallone’s Lower Premiums, Faster Payments Act would end arbitration for services on or after Jan. 1, 2028. Insurers would pay a benchmark based on each plan’s 2019 median contracted rate, adjusted for inflation, within 30 days. The bill would bar court review of how that benchmark is calculated and require regulators to audit at least 25 plans a year, according to Medical Economics and a Holland & Knight analysis.

Pallone said the bill “will replace the broken arbitration system with a fair and timely payment process,” according to Fierce Healthcare.

The insurance industry has pushed for tougher action. AHIP spokesman Chris Bond said more is needed to protect Americans from “unconscionable price gouging by some PE-backed providers and IDR middlemen,” Healthcare Finance News reported. A federal rule finalized in June lets parties group more claims together and lowers administrative fees, but critics say it does not address high provider win rates.

Physician groups oppose ending arbitration. The No Surprises Act Enforcement Act, H.R. 4710 and S. 2420, would instead let regulators penalize plans that miss payment deadlines after an arbitration decision, an approach backed by the American Medical Association.

The bill is led by Rep. Greg Murphy, R-N.C., and Sen. Roger Marshall, R-Kan., both physicians, with bipartisan cosponsors. Plans that miss deadlines would owe three times the difference between their initial payment and the award, plus interest.

“Giving health insurance companies even greater control over physician payments is not the solution,” said Dr. Patrick Giam, president of the American Society of Anesthesiologists, in a joint statement with emergency physicians and radiologists. The groups cite federal data showing insurers lost by default on 24.5% of 2025 line items and offered $1 or less on 8.2%.

Doctors argue their bigger problem is getting paid after they win. A 2024 survey by the Emergency Department Practice Management Association found that 24% of emergency practices reported arbitration awards that were unpaid or paid incorrectly by the deadline, the AMA said. The enforcement bill aims to close that gap.

For most patients, today’s protections stay in place no matter which side prevails. People who receive a surprise bill for covered emergency care or out-of-network care at an in-network facility can contact the federal No Surprises Help Desk at 1-800-985-3059.

The bigger household effect is premiums. One analysis estimated that arbitration added about $22.4 billion in costs over four years. Pallone has said arbitration costs were the main driver of a 10% premium increase in New York’s state employee plan. An analysis from the ERISA Industry Committee, which represents large employers, also tied higher employer insurance costs to arbitration, Fierce Healthcare reported. No official estimate yet shows how much either bill would save.

Pallone is the top Democrat on the House Energy and Commerce Committee. MedicalDaily will track both bills and any surprise-billing provision attached to a year-end spending deal.

What does the No Surprises Act do for patients?

It limits what patients pay for many out-of-network emergency and hospital-based services to in-network cost sharing. Insurers and providers settle the rest.

It would end arbitration for services starting in 2028 and set payment at a benchmark based on median in-network rates. Insurers would have to pay within 30 days.

What does the enforcement bill do instead?

It keeps arbitration but lets regulators penalize plans that fail to pay awards on time. Physician groups support it.

Possibly, since arbitration awards are paid by insurers and can affect premiums. No official estimate yet shows the savings from either bill.

Contact the No Surprises Help Desk at 1-800-985-3059. Keep the bill, your explanation of benefits, and any notices from your insurer.