How states can take the lead on mitigating surprise out-of-network billing, -AND Hospital groups push for seat at table as lawmakers address 'surprise billing'

CALAAEM News Service calaaem.news.service at gmail.com
Tue Feb 26 17:54:51 PST 2019



 

Feb. 25, 2019

 

How states can take the lead on mitigating surprise out-of-network billing

 

 
<https://www.fiercehealthcare.com/hospitals-health-systems/hospital-groups-p
ush-for-seat-at-table-surprise-billing-problem?mkt_tok=eyJpIjoiWWpFd01HVXlaa
mhsTlRnNSIsInQiOiJBQU1hcWZWWUJzVktmYm9aYjBBd2ZCOFVkeTVqUTJiVzROMTBJRHQzVzhXY
1wvK01NYU5PV1Ftc0U5djF3aEh0UHNqc0xBM1wvQ3l2Q1htMFJhK0xuWGd5QVJ4Z25NT3VaWFAwb
1d5V0ltTVRoUit2UHNQV1VLUjc4TytyVlhBS0w4In0%3D&mrkid=905528&utm_medium=nl&utm
_source=internal> FierceHealthcare

 

by Jacqueline Renfrow | Feb 20, 2019 4:08pm

 

There are policy options, at the state level, which could help mitigate the
costs of surprise out-of-network billing. According to a recent report from
the USC-Brookings Schaeffer Initiative for Health Policy, surprise
out-of-network costs, such as ambulance transports or care delivered by an
out-of-network physician at an in-network hospital, are a huge burden.

 

If not prohibited by the state's law, 1 in 5 visits to the emergency
department results in a surprise out-of-network bill. And 50% of all
ambulance cases involved an out-of-network ride in 2014, according to the
report.

 

"The financial consequences of surprise out-of-network bills can be
substantial," noted the paper. Especially for patients enrolled in HMOs, who
can be liable to provide payment for all charges on out-of-network care.

 

According to data in the report, collected from a large national insurer,
out-of-network emergency physicians charged about eight times what Medicare
pays for the same service. And a survey of American Society of
Anesthesiologists reports that contracted payments to anesthesiologists
averaged 350% of the Medicare rates in 2018.

 

Plus, the costs can also be high for the physicians who are charging for
out-of-network billing. These doctors often end up settling with patients or
health plans for payments below what was fully charged. Collecting an
out-of-network bill has more administrative hassle, too, according to the
report. 

 

But the problem lies at the hospital level, where it would be more expensive
to require its out-of-network physicians to go in network, in turn, making
it more expensive for insurers to encourage hospitals to take this approach,
the report found. Then, physicians would most likely require higher stipends
to compensate for the loss of income.

 

Therefore, the demand would likely need to come from patients asking that
hospitals pay the balance to physicians, which is unlikely as many patients
only require these arrangements in an emergency or are not aware of surprise
out-of-network charges at all, the report said.

 

Still, the American Hospital Association (AHA) and several other hospital
groups sent a letter (PDF) urging Congress to enact legislation that
protects patients from surprise medical payments. 

 

"The last thing a patient should worry about in a health crisis is an
unanticipated medical bill," AHA President and CEO Rick Pollack said in a
statment. "We must protect patients from surprise bills that could
unintentionally impact their out-of-pocket costs and undermine the trust and
confidence patients have in their caregivers."

 

The Brookings paper sets forth five approaches that individual states need
to consider in order to change the current policies surrounding surprise
out-of-network billing. 

 

*	Take the patient out of the equation and require insurers and
providers to resolve the problem and payment.

 

*	Patients should be made aware of all out-of-network services within
a facility before a procedure occurs. 

 

*	States should limit or ban all billing without prior consent, in
writing, from patients. 

 

*	States have the power to manage enforcement through existing
processes for managing licensure and certification and resolving patient
disputes. 

 

*	Due to ERISA-which bars states from regulating self-insured employer
health plans-state policy needs to focus on the regulation via health care
providers. 

 

Brookings suggests a policy setting "billing regulation," which caps or sets
limits on what out-of-network providers can charge patients in surprise
situations.

 

The second approach, "contracting regulation", makes it impossible for
services to be out-of-network when the facility itself is in network.
Although if new contracts are formed, facilities will need to be mindful of
state kick-back laws and rules about the contracts between healthcare
providers and insurers. 

 

The paper also suggests a billing regulation approach or a hybrid approach,
drawing upon billing regulation and contracting regulations. The authors
believe either two options could be enacted on the federal level as well,
with only a few modifications. 

 

"If pursuing option No. 1, the federal government could require self-insured
(in addition to fully-insured) health plans to hold enrollees harmless for
any costs beyond normal in-network cost- sharing amounts associated with
surprise out-of-network services," the paper noted. "If enacting a federal
solution, Congress would also have to decide whether to supersede existing
state reforms, which range widely in their comprehensiveness and
effectiveness." 

 

The letter to Congress agreed with the sentiment that federal decisions
should be mindful of state regulations and ultimately leave patients out of
any payment debates.

 

Feb. 25, 2019

Hospital groups push for seat at table as lawmakers address 'surprise
billing' 

 

 
<https://www.fiercehealthcare.com/hospitals-health-systems/hospital-groups-p
ush-for-seat-at-table-surprise-billing-problem?mkt_tok=eyJpIjoiWWpFd01HVXlaa
mhsTlRnNSIsInQiOiJBQU1hcWZWWUJzVktmYm9aYjBBd2ZCOFVkeTVqUTJiVzROMTBJRHQzVzhXY
1wvK01NYU5PV1Ftc0U5djF3aEh0UHNqc0xBM1wvQ3l2Q1htMFJhK0xuWGd5QVJ4Z25NT3VaWFAwb
1d5V0ltTVRoUit2UHNQV1VLUjc4TytyVlhBS0w4In0%3D&mrkid=905528&utm_medium=nl&utm
_source=internal> FierceHealthcare

 

by Tina Reed | Feb 21, 2019 8:54am

 

As the problem of "surprise billing" at hospitals around the country gains
scrutiny from the White House and Congress, a collection of major hospital
groups indicated they want a hand in shaping the conversation.

 

In a letter sent to Congressional leaders on Tuesday, the groups-which
include the American Hospital Association and Federation of American
Hospitals-laid out principles they want lawmakers to consider as they seek
to address the problem over the next few months.

 

Specifically, their solutions took aim at policies by health payers and
called for protections for patients but notably also opposed the
controversial practice of balance billing by providers.

 

It's the latest in the back and forth in the industry over who is actually
to blame for surprise medical bills, or the practice of charging patients
for care that is more expensive than anticipated or not covered by their
insurance. In December, a group of insurance, business and consumer groups
announced they'd banded together to push for stronger patient protections
and released their own guiding principles for the conversation.

 

"We are fully committed to protecting patients from "surprise bills" that
result from unexpected gaps in coverage or medical emergencies," the letter
from the hospital groups, which also included America's Essential Hospitals,
Association of American Medical Colleges, Catholic Health Association of the
United States and the Children's Hospital Association said.

 

"We appreciate your leadership on this issue and look forward to continuing
to work with you on a federal legislative solution," they said.

 

Among the principles, they called for:

 

Congress to define "surprise bills" saying they may occur when a patient
receives care from an out-of-network provider or when their health plan
fails to pay for covered services. They also called for policies to protect
patients financially and said providers should not balance bill, meaning
they should not send a patient a bill beyond their cost-sharing obligations.

*	Protections for patients seeking emergency care from being denied
payment by a payer if, in retrospect, the health plan determines was not an
emergency. They also supported moving the patient from health plan/provider
negotiations, saying health plans must work directly with providers on
reimbursement, and the patient should not be responsible for transmitting
any payment between the plan and the provider.

 

*	The preservation of the role of private negotiation between health
plans and providers in determining appropriate payment rates.

 

*	"The government should not establish a fixed payment amount or
reimbursement methodology for out-of-network services, which could create
unintended consequences for patients by disrupting incentives for health
plans to create comprehensive networks," the groups wrote. 

 

*	Ensuring patients have access to comprehensive provider networks and
accurate network information through their health plans. Hospitals have
received criticism that surprise bills have resulted in emergency
departments or surgical procedures when a patient receives care in an
in-network hospital by an out-of-network healthcare provider.

 

The letter came the same day as a Brookings Institution report which said 1
in 5 visits to the emergency department results in a surprise out-of-network
bill in states that don't prohibit them. About half of all ambulance cases
involved an out-of-network ride in 2014, according to the report.

 

 

 

 

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

 

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