The result is billions of dollars in payments, which can have a significant impact on how doctors and hospitals negotiate prices with insurance companies, which can affect the premiums of millions of Americans.
“This is probably one of the most important reviews in the healthcare system. [Affordable Care Act] ACA “. A spokesperson for Coalition Against Surprise Medical Billing, who represents insurance companies, employers and union groups and works with patient groups, said. “There is certainly no end to the fight to ensure that these registrations take place.”
The coalition is a provisional Biden administration that directs arbitrators to rely primarily on a single factor (median rate within a network of geographic areas) in resolving disputes between providers and payers. Supports final rules. It sponsored multiple 6-digit digital ad purchases, including those going through Christmas, and urged regulators to continue the course.
A senior health bureau official who asked to speak anonymously on the issue told POLITICO that he was not surprised at the level of support for the issue.
“These rules fix this broken system,” officials said, “and there’s a lot of money at the table.”
2 years to produce
How to get here: For years, the story of patients facing financially unfavorable medical costs from off-network doctors and hospitals has been a staple of news coverage, urging state legislators and Congress to tackle the problem. .. It took two years for Congress to pass the no-surprise law. That progress was often hampered by intense lobbying activities, including those funded by a private equity-owned physician group that had a price tag of about $ 30 million.
Former President Donald Trump signed the bill last year, but the Biden administration has written rules governing how it will be implemented.
Provider groups have recently claimed from HHS Secretary Xavier Becerra about providers that are “overcharging” as evidence of government immobility, claiming that the rules by the Department of Health and Human Services (not yet final) support insurance companies. Point out the comment of.
Chris Hartmeier, vice president of policy analysis at Blue Cross Blue, said the insurer group “takes into account real health costs and regional market dynamics” and therefore uses the median in-network rates. I argue that this is the right way to go. Shield Association.
This figure “reflects the payments made by similar providers who choose the contract for the same service in the market,” he added.
A group of patients lobbyists told POLITICO at the moment of “Groundhog Day.” Many of the issues that are currently being developed are the same that plagued the legislative process.
Battle line: Hospitals and doctors argue that the Byden administration’s decision to emphasize the median in-network rates calculated by insurers will bring significant benefits to large insurers when negotiating the cost of services.
Insurance companies have incentives to keep fees on the network low so that they don’t pay too much to doctors outside the network. And they say that if they choose to stay outside the insurance company’s network, payers will know that doctors and hospitals are almost unreliable.
“The only thing that goes out of the network is, in fact, the doctor’s control over what the contract looks like,” said Randall Clark, president of the American Society of Anesthesia. “If an insurer can treat us the same whether we are on or off the network, the insurer has no impetus to negotiate a fair contract.”
According to industry associations representing healthcare providers, the law describes several other factors that need to be equally weighted when calculating the cost of services, such as physician experience and procedural complexity. .. These metrics are In the dispute resolution process, the Biden administration’s rules are less important than the median rate indicators in the network. Providers say they put them at a disadvantage before the process begins.
Others weigh
There was also strong opposition from ambulance providers operating primarily outside the insurance network. In their view, the more balanced process takes into account other factors such as the type of aircraft used and the patient’s acuity.
The industry also has problems with the rules that treat all ambulance services in the same way. It brings together those that negotiate with insurance companies as part of a larger hospital system and those that negotiate independently and together.
The industry’s voice was the loudest overall, but patient groups and unions, including the American Heart Association, AFL-CIO, and Families USA, said they were in favor of the Biden administration’s statutory interpretation and kept costs and premiums down. I am.
Government Thoughts: Federal regulators have denied the idea that a myriad of factors should be considered equally, and in rulemaking, to define a median rate within a network within a geographic region, called a qualified payment amount. Note how much space was given within the no-surprise law (QPA).
HHS executives told POLITICO that hospitals and doctors exaggerated the harm these rules do to their profession.
“Some of the allegations made in these conversations, or generally about the problem, are kind of ridiculous,” says patient groups, unions, providers, insurance companies, and more. Officials who have called and held meetings with representatives said.
Emphasis on a single factor also provides certainty about what arbitration will look like, so that regulators write, avoid independent dispute resolution processes, and reach their own consensus. Can lead to.
Large print of the bill: HHS recently reported that approximately one in five Americans received hundreds of thousands of dollars invoices from visits to emergency rooms or after selective surgery or childbirth at a hospital within the network. Announced.
With a group of employers lobbying on this issue We support linking arbitration terms to the median rate within the network and point out this type of evidence as a reason providers should be skeptical.
“The fact that the current system pays significantly different amounts for the same exact service in the same exact area, regardless of quality-that’s not the advantage of the system, isn’t it?” ERISA Industry Commission spokeswoman Executive Vice President James Gelfand said. “So are they complaining that we are making changes to it? That is, shout me the river.”
Becerra hinted that the provider is taking advantage of the broken system that his agency is trying to fix.
“People who are overcharged either have to fasten their belts and do it well, or they don’t last long,” Besera told Kaiser Health News last month. For them to do business. “
“Not so simple”
Providers, on the other hand, say they are unfairly targeted.
“It’s not as easy as you think the administration wants or portrays it,” said Laura Worcester, senior vice president of advocacy and practice at the American College of Emergency Medicine.
“I feel like I’m still painting with this brush that the provider is greedy. [they] It’s always overcharged, “she said.
Rate slash: Even before the law comes into force, providers claim that the insurance industry is already taking advantage of imminent rules that will come into force earlier this year.
According to a letter sent to Congress last week by the American College of Emergency Physicians, three insurers need to accept North Carolina providers a 20-40% reduction in payments.
“For one insurance company, you might think,” OK, that doesn’t end your business. ” But if there are four or five different insurance companies and all of them do this, Worcester says, “I can’t keep it.”
The group said some contracts between plans and providers haven’t changed for more than a decade, and insurers have begun demands citing the imminent enforcement of the No Surprise Act.
One of the insurance companies, Blue Cross Blue Shield, North Carolina, addressed this claim in a blog post. It identified “54 of the most expensive medical practices throughout the state,” the post said. “We asked these providers to work with us to adjust prices to be more in line with our peers.”
Legal issues: Three separate proceedings against the rules have been filed in federal court. The latest was launched on December 9th by the American Hospital Association and the American Medical Association.
It follows those from the Aviation Medical Services Association and the Texas Medical Association, which submitted them in November and October, respectively. All of them attack the median estimation of contract rates within the network in arbitration.
The earliest time to start arbitration is March, but the court will not reach a decision before the law comes into force.
