Efforts are underway both in Washington and on Beacon Hill to help resolve the problem of “surprise billing.”
Surprise billing occurs when a patient receives care from an out-of-network provider that is not covered by their insurer. The most common scenarios occur when a patient needs emergency services and are cared for by an out-of-network physician or in an out-of-network facility, or a patient receives treatment at an in-network facility but is unknowingly cared for by an out-of-network clinician -- for example, by an anesthesiologist.
In these cases, all stakeholders currently debating the issue agree that patients should not be responsible for these unexpected bills, and that insurers and providers should work together to determine payment. The challenge centers on just how to determine an appropriate payment rate.
The Massachusetts legislature is addressing the issue, but whatever law the state may eventually pass will not cover the many people who are enrolled in self-funded, employer-sponsored plans regulated through the Employee Retirement Income Security Act of 1974 (ERISA). It will take federal legislation to apply surprise billing protections to those ERISA plans. Congress is debating three major pieces of bipartisan surprise billing legislation: a discussion draft from the House Energy and Commerce Committee entitled the No Surprises Act, a Senate bill from a working group led by Sens. Bill Cassidy (R-La.) and Maggie Hassan (D-N.H.) entitled STOP Surprise Medical Bills Act (S. 1531), and a discussion draft from the Senate Health, Education, Labor and Pensions (HELP) Committee entitled Lower Health Care Costs Act containing three separate options to address surprise billing.
As the debate continues, MHA has laid out some basic guidelines that hospitals believe should be part of any legislation – both state and federal.
First, patients should be protected from surprise bills and should pay no more than they would have paid if the service had been rendered in network. Second, for planned non-emergency care, patients should have easily accessible network information from their health plan. The most common way that individuals and families find in-network clinicians and hospitals is through their health plan’s provider directory. Patients should have access to comprehensive and accurate online provider directories through their health plan to know which providers and services are in their network. Health plans should also work with providers to ensure that they can provide patients with accurate information regarding network status. Additionally, health insurers must create and maintain robust provider networks so that out-of-network incidents are minimized.
Lastly, a fair and equitable reimbursement structure must be created that does not diminish the incentive for payers to negotiate fair rates or encourage providers to leave the network. The American Hospital Association (AHA) testified recently that Congress should “preserve the ability of providers and insurers to negotiate private contracts and not establish a fixed payment amount for out-of-network services. Arbitrary reimbursement rates could disrupt local market forces in ways that could have significant negative unintended consequences. Chief among them is the disincentive this will create for health plans to maintain adequate networks and act as good business partners to their providers. Without sufficient network adequacy requirements that address specific critical specialties and subspecialties, insurers can simply default to a benchmark payment and decline to contract with many different types of physicians.”
MHA supports using an independent dispute resolution process to resolve rate disagreements similar to the model adopted by NY State, as opposed to having a third party set default reimbursement rates.