Providers, Insurers Parse What They Could Support – And What They Won’t – In Surprise Billing Solution

Surprise Billing SolutionWhile both providers and insurers have found it difficult to agree on a solution to surprise billing, experts on both sides expressed support Tuesday for banning the practice – thereby forcing insurers and providers to work out payment disputes among themselves—when patients have gone to in-network hospitals.

The approach, which has been tried in Oregon, was among the few areas of agreement during a House subcommittee hearing on the topic of surprise billing.

“In Oregon, consumers did get taken out of the middle. That’s exactly what we’re talking about here. No more balance bills. They can have the piece of mind that if they have an emergency, they won’t get those bills,” said Jeanette Thornton, the senior vice president for product, employer and commercial policy at America’s Health Insurance Plans (AHIP). “As for a benchmark, I do understand they allow a reasonable payment rate from the plan process and that’s exactly the type of approach we support.”

Tom Nickels, executive vice president of government relations and public policy at the American Hospital Association (AHA), agreed.

“That is what we’re all recommending happen at the federal level, as well. Our view is it is best that those negotiations for the other part—the part the insurance wants to pay, the provider wants to get—should be worked out between the insurer and the provider,” he said.

They were speaking to potential solutions that could be tried at the federal level after several pieces of legislation have recently been proposed or introduced; these include surprise billing bans or requirements that patients only be charted in-network cost-sharing rates in emergency situations as well as requirements that effective notice of out-of-network care estimated costs be provided in advance of care in non emergency situations. Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or not covered by their insurance, has received a flood of attention in the past year as other news organizations have undertaken investigations into patients’ most outrageous medical bills.

In his opening statement, Ways and Means Committee Health Subcommittee Chairman Rep. Lloyd Doggett pointed out there are multiple places for disagreement and urged the subcommittee to search for areas of agreement. For instance, he said, the Trump administration has opposed solutions to surprise billing that require arbitration or rate-setting but has indicated it would support bundling payments. “I basically support any solution that can get 218 votes in the House and protect patients, gain Senate approval and [Trump’s] signature.”

Some of the largest groups representing insurers have called for legislation to block physicians from sending surprise bills in case of emergency or when a patient had no choice in their provider and pushed for facilities to be required to inform patients of their doctors’ network status and consent for out-of-network care. They also asked for setting reimbursement rates, ensuring these protections apply to all health plans and avoiding the use of costly arbitration that can keep consumers stuck in the middle. Meanwhile, provider groups have called for a solution that would allow insurers and providers to retain their ability to negotiate appropriate payment rates.

While experts on Tuesday agreed on removing patients from the middle of negotiations, those sticking points remained.

For instance, experts from the American Medical Association (AMA) and AHA spoke strongly against, warning of “unintended consequences” when it came to rate setting.

“The notion that there’s some kind of a benchmark, some sort of national rate, something that is an average would work in rural America is one of those unintended consequences,” Nickels said. “That physician, that hospital should be negotiating with the insurer and it shouldn’t be based on some number that someone comes up with arbitrarily that I think will actually result in fewer hospitals and physicians being in-network because it can default to that particular rate.”

Meanwhile, the idea of focusing on network adequacy, supported by both the AMA and the AHA, earned warnings from AHIP. “Health plans are strongly regulated on network adequacy in rural areas,” Thornton said. “They would be required to contract with that hospital anyway. We see surprise billing happen in large networks and in small networks. I don’t think it’s a network adequacy issue at play here but other dynamics.”

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