Progress on Surprise Billing

U.S. Ways & Means Gets It Right on Surprise Billing

The U.S. House Ways & Means Committee, chaired by Massachusetts Democrat Richard Neal, announced that it has reached bipartisan agreement to resolve the “surprise billing” issue.
The Ways & Means proposed solution stands in contrast to other proposals that have been floated recently in Congress, including a recent joint proposal from the Senate HELP and House Energy & Commerce committees that hospitals believe would ultimately harm patient access to care.
Surprise billing occurs when an insured patient receives services from an out-of-network provider in an emergency situation (say, ED care after a car accident) or is treated by an out-of-network clinician at a facility that is in network (for example, the anesthesiologist is the only member of a surgical team not in the patient’s insurance plan). Just about every stakeholder, including hospitals, believes that patients should be protected from surprise bills and should pay no more than they would have paid if a service had been covered under their insurance plan. Determining how the out-of-network provider should be reimbursed has been the subject of debate.
The Ways & Means plan – the full details of which are not yet public – protects patients from surprise billing scenarios and calls for arbitration when providers and insurers disagree on the reimbursement for out-of-network services. This approach respects private market dynamics between insurance companies and healthcare providers by allowing them to work out differences without interference. If the parties cannot come to agreement, the Ways & Means proposal provides for a structured and impartial process to reach resolution. 
The alternative being pushed by insurance companies is for the government to set a “benchmark” rate, meaning that every provider in a specific market gets some sort of government mandated rate for the care provided. Because certain providers in a similar geographic area may have substantially different costs, an artificially low, across-the-board reimbursement rate could hurt those providers that are already at risk. 
MHA President & CEO Steve Walsh said of the Ways & Means proposal, “The hospital community is grateful for Chairman Neal’s extraordinary leadership on this issue. The Ways & Means proposal provides important protections and transparency for patients without undue government interference in private contracts. It is directly responsive to the priorities of the hospital and physician communities.”
Walsh and Mass. Medical Society President Dr. Maryanne Bombaugh met recently with Neal on Capitol Hill. Last week, this Cutting through the clutter on surprise billing op-ed from Walsh and Mass. Medical Society President Dr. Maryanne Bombaugh ran part of The Boston Globe’s opinion series on choosing, using, and losing healthcare.

CMS to Follow Court Guidance and Reimburse Hospitals

CMS has relented and will repay hospitals across the U.S. that sued to recover reimbursement cuts resulting from CMS’s so-called site-neutral policy.
In the 2019 outpatient prospective payment system rule (OPPS) released at the end of 2018, CMS reduced Medicare payments for certain services provided at grandfathered off-campus hospital provider-based departments (PBDs). These PBDs are defined as practice locations that are not located in the immediate proximity of the main hospital but are nonetheless closely integrated with and controlled by the hospital. (Some examples are stand-alone oncology clinics or medical offices offering specialized care.) The new federal rule essentially treated the grandfathered off-campus provider-based departments as similar to physician offices – and paid them at a lower rate.
The American Hospital Association and other provider groups sued in December 2018, arguing that off-campus PDBs often have higher costs, and that CMS exceeded its authority and overrode Congressional intent by issuing the final OPPS with the payment cut. This September, a federal district court judge ruled in favor of the hospitals, but it remained unclear how and when CMS would reimburse hospitals.
However, last week CMS announced that it would begin reprocessing past claims and refund the 2019 monies owed to hospitals. Interestingly, CMS’ 2020 OPPS rule continues to phase in the same off-campus provider-based department cuts that the court vacated. It remains to be seen how CMS will resolve the discrepancy going forward.

MHQP’s List of Primary Care Practices That Patients Admire

MHQP – the Mass. Health Quality Partners – last week announced the winners of its 2019 Patient Experience Awards. The two-year-old award program recognizes primary care practices that perform highest on MHQP’s patient experience survey. More than 60,000 responses were submitted to the annual survey of commercially insured patients across Massachusetts. Awards are presented to the top overall performers in adult primary care and pediatrics, as well as the highest performers in nine performance categories: 1) patient-provider communications, 2) coordinating patient care, 3) how well providers know their patients, 4) assessment of patient behavioral health issues, 5) ease of access to care, 6) empowering patient self-care, 7) office staff professional excellence, 8) pediatric preventative care, and 9) assessment of child development.

Should Doctors Ask Patients About Guns?

The Joint Committee on Public Health last Tuesday heard testimony on House Bill 2005, An Act to Prevent Gun Violence, which would mandate that the state Department of Public Health create a program to “systematically screen all patients for the presence of firearms in the home.”
The bill from Rep. Jon Santiago (D-Boston) would permit DPH, after consultations with medical groups, to issue regulations “establishing (1) the means by which and the intervals at which patients shall be screened for the presence of firearms in the home and (2) guidelines for safety counseling for individuals that screen positive for the presence of firearms in the home.”
The Gun Owners' Action League of Massachusetts slammed the bill in a blog posting, saying it “treats simple gun ownership as a disease.” Boston Health and Human Services Chief Marty Martinez testified that, “We know that gun safety is a public health issue. As such, doctors are uniquely positioned to help prevent gun-related injury and death.”

Transition at Wellforce

Effective in January 2020, Michael J. Dandorph becomes the new president and CEO of Wellforce, the health system comprising Tufts Medical Center, Circle Health, MelroseWakefield Healthcare, and the Home Health Foundation. Dandorph replaces Norm Deschene, who retired in December 2018. Since then, Michael Wagner, M.D. has served as interim CEO and will return to his position in January as Wellforce’s chief physician executive. Dandorph joins Wellforce from Rush University System for Health and Rush University Medical Center in the metropolitan Chicago area. Before his posts at Rush, Dandorph spent more than 17 years at the University of Pennsylvania Health System (Penn Medicine) as senior vice president of strategy and business development. Dandorph has a B.S. from William Paterson University of New Jersey and an MHA from Cornell University.

2020 Joint Commission Update

Friday, January 17, 2020; 8:30 a.m. - 2:30 p.m.
Conference Center at Waltham Woods, Waltham, Mass.


Hospitals need to stay abreast of the evolving compliance issues and shifting priorities regarding Joint Commission accreditation. At this year’s conference, you’ll hear from Gail Weinberger, director for state relations at The Joint Commission, and an expert on its standards. She’ll provide an update on the challenging standards from 2019 and highlight some of the new ones for 2020. The program also features a hot-topics session and concludes with a panel of representatives from recently surveyed hospitals sharing tips and updates about current priorities. Click here to learn more.

John LoDico, Editor