Joint Committee on Financial Services
The Massachusetts Health & Hospital Association (MHA), on behalf of its member hospitals, health systems, physician organizations, and allied healthcare providers, appreciates this opportunity to testify regarding legislation that addresses out-of-network/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 accesses emergency services outside their network or a patient receives care at an in-network facility but is unknowingly cared for by an out-of-network clinician. Massachusetts hospitals are committed to protecting patients from surprise bills and support sensible legislation to accomplish this goal. As a result, we support certain provisions in these bills, such as holding the patient harmless and increasing transparency, and oppose others that would create administrative burdens, disrupt provider networks, or unnecessarily confuse patients.
Specifically, MHA is supportive of those provisions in these bills and other proposals before the legislature that provide:
Patients should be protected from surprise bills and pay no more than they would have paid had the service been rendered by an in-network provider. Processes must be developed to hold the patient harmless, take the patient out of the middle, and require any negotiations around reimbursement be between the provider and insurer.
In an effort to prevent patients from receiving a surprise bill, some MHA member hospitals are encouraging their physician groups to contract with the same plans in the hospital’s network. While this is successfully happening in some communities, there are market forces that may make this challenging in some areas.
There must be sufficient disclosures by both providers and insurers so that patients can, in non-emergent situations, make informed healthcare decisions including whether or not a particular clinician or hospital is in the insurer’s network. Creating increased consumer awareness and education about the benefits and risks of receiving care out-of-network as well as how to verify provider participation status would help to reduce the number of surprise bills.
The most common way individuals and families find clinicians and hospitals in their network is through their health plan’s provider directory. However, these directories are not always accurate. H913/S610, which is strongly supported by MHA, seeks to address this challenge by establishing a task force to make recommendations to improve the accuracy of these directories. The bill language also makes interim improvements including ensuring that provider directories are easily searchable, available to the public, and regularly updated.
Ensure Adequate Provider Networks
Insurers must establish comprehensive provider networks sufficient to provide all covered services so that patients seeking treatment do not have to consider going outside of the network to receive medically necessary care.
Fair Reimbursement Methodology
Providers must be able to negotiate appropriate payment rates with health plans. In situations where a provider is out-of-network, we support using an independent dispute resolution process in those circumstances where a provider and a health plan are unable to reach an agreement. We oppose using a government agency such as the Health Policy Commission or CHIA to establish default rates.
There are other states that have successfully implemented surprise billing legislation, including New York in 2015 and New Jersey last year. Both of these states strengthened protections for patients, increased transparency, and established arbitration procedures. We are looking to them for best practices as we continue to work with our members and the legislature on developing a sensible approach to surprise billing.
It is important to note that many of our members report that surprise billing occurs most frequently with national or self-insured health plans, which would be outside the purview of any Massachusetts legislative intervention. We are working with our colleagues at the national level on potential surprise billing solutions that would address these payers.
Finally, some of these bills also address facility fees. While this is a separate issue, MHA supports transparency of such fees as put forth in our priority legislation SB700. The bill ensures that patients are informed and fully understand the situations in which a facility fee may be applied to a service or procedure, consistent with Medicare standards. The bill is currently before the Joint Committee on Health Care Financing.
Thank you for the opportunity to offer comments on this important matter. If you have any questions or concerns or require further information, please contact Michael Sroczynski, MHA’s Senior Vice President of Government Advocacy, at (781) 262-6055 or email@example.com