What is the surprise insurance gap?

Insurance companies are shifting hundreds of millions of dollars each year in medical costs to patients. Insurance companies are narrowing their physician networks and sticking consumers with the bill for the difference between in and out of network doctors – often in emergency care situations when the patient doesn’t have any choice. Say you are in an auto accident and rushed to the ER.  The treatment you receive may cost $1000 but if the emergency room doctor on call that day isn’t in your insurance company’s network, the insurance company will only pay a small portion of the bill, leaving the rest for the patient, even though the patient didn’t choose the doctor who treated them or even have an opportunity to ask about in or out of network coverage.  

The Solution: End the Insurance Gap

A comprehensive and fair solution needs to address the underlying issues that cause surprise bills.  Our legislative guidelines ensure strong patient protections, improve transparency, and establish a fair reimbursement standard.


  • Patients should not be financially penalized for unexpected out-of-network (OON) care.
  • In-network rates should be applied to any patient deductibles and cost-sharing.
  • An appropriate and fair standard should be created for out-of-network services using a reimbursement schedule connected to an independently recognized and verified charge-based database.
  • Physicians should no longer submit balance bills to patients for unexpected out-of-network care.
  • Insurers should be prevented from providing misleading and confusing information regarding coverage.
  • Strong penalties for insurance companies and physicians that violate this law should be established so patients are always protected.
  • Greater transparency should be required of insurers. Specifically, network provider directories should be easily accessible for both patients and physicians, updated immediately and completely accurate.

Physicians for Fair Coverage developed The Patient Protections and Transparency Act of 2018, model legislation designed to create a fair, comprehensive solution that will end surprise bills for unexpected, out-of-network care, and provide protections for patients from the financial impact that narrower networks and cost-shifting trends within health insurance can create.  State legislatures across the country are using these guidelines to bring and end to surprise insurance gaps.


You can download a section-by-section summary of The Patient Protections and Transparency Act of 2018 here.

You can download the bill language for The Patient Protections and Transparency Act of 2018 here.

We would like to talk to you about our efforts and active legislation in your state.  Please contact us at info@endthesurpriseinsurancegap.org or call us at 1-202-802-9040 for more information about how to get involved in ongoing policy efforts in your area.


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