Congress will soon return to Washington, D.C., and get back to work on a long list of unfinished business that must be tackled before the year ends. Included on that list is the issue of surprise billing.
In the weeks leading up to the August recess, Congress had taken significant steps in moving legislation aimed at tackling the issue of surprise billing by passing bills out of committees in both the House and Senate.
Both bills would protect patients by limiting their out-of-pocket costs to amounts they would have owed if they had been treated by an in-network physician. And the California Medical Association (CMA) agrees patients should be protected from surprise medical bills. However, neither bill holds health insurers accountable.
Both bills would resolve payment disputes between physicians and insurers by setting out-of-network payments at the median amount each insurer pays for in-network care. However, neither bill includes a fair process that incentivizes insurers to contract at reasonable rates.
These are serious flaws that need to be fixed.
The physician advocacy community will have opportunities with two other House committees to make further improvements on these and other elements in the legislation, but we can’t leave anything to chance. That’s why physician advocacy on this issue is so important.
Urge Congress to Adopt New York Surprise Coverage Law
The current House and Senate bills mirror California’s unsuccessful surprise billing law (AB 72). While California succeeded in protecting patients from surprise medical bills, the rest of the law is not working. Insurers across the state are cancelling long-standing contracts with physician groups, particularly anesthesiologists, or imposing significant (25-45%) payment cuts. Insurers have decided they no longer need to contract because they can just pay the low rate established by state law.
Physician networks are diminishing and access to care is in jeopardy for in-network care, as well as for emergency physicians and on-call surgeons, anesthesiologists and other specialists who care for patients in emergencies. If on-call physicians no longer have a contract and will only be paid the low rate in the law, they cannot afford to accept call responsibilities. In fact, the Department of Managed Health Care has reported a 48% increase in patient access to care complaints since the passage of AB 72.
CMA and all of organized medicine are urging Congress to support H.R. 3502, the “Protecting People from Surprise Medical Bills Act,” authored by physician Congressmen Raul Ruiz, M.D., (D-CA) and Phil Roe, M.D., (R-TN), which is based on the proven, successful New York model.
A Fair and Balanced Dispute Resolution Process
It is critical that there be a fair and balanced mechanism for arriving at the appropriate rate for those providers who do not have a contract with a given insurer. At no point should negotiated, discounted in-network rates be used as a benchmark to determine fair payment to out-of-network physicians, and at every point commercial data from independent sources should inform the payment standard.
When the minimum payment from the payor for out-of-network care is insufficient, an independent dispute resolution process (IDRP) should be developed to determine a fair payment by the health insurance company for the care provided. The IDRP should be structured with clear factors that an arbiter, familiar with health care billing, must consider when deciding, such as the complexity of the case, the experience of the physician, and the rate that physicians charge for that service in the area.
To ensure that patients are completely protected, benefits should be assigned to the physician or other providers so that they may pursue payment for services provided directly with the insurer without further involving the patient. This is to ensure that games that have been played by insurers, such as making periodic payments directly to the patient, are not allowed and that the patient is fully kept out of the middle.
Congress should ensure that patients are reasonably able to access the benefits their health plans promised when they signed up for coverage. Insurers must also ensure that their provider directories are accurate and up-to-date so patients can make informed decisions about their care.
Physicians Voices Must Be Heard
We need to be sure that physicians’ voices have been heard on this issue. CMA is urging physicians to contact their members of Congress and ask them to support surprise billing legislation that protects the patient and holds insurers accountable for failing to provide adequate networks of physicians.
Visit the American Medical Association Physicians Grassroots Network (physiciansgrassrootsnetwork.org) to send a message to your members of Congress. Tell them to:
- Protect patients from surprise medical bills.
- Establish a fair process that incentivizes insurers and physicians to contract, with a dispute resolution process that uses a reasonable market-based payment benchmark.
- Preserve patient access to in-network physicians, emergency physicians and on-call physician specialists who care for patients in emergencies.
- Cosponsor Ruiz-Roe H.R. 3502 “Protecting People from Surprise Medical Bills,” based on the proven New York model.
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