by Kate Alfano, CMS Communications Coordinator
Featured in the September-October 2019 Colorado Medicine Colorado Medicine.
Congress has taken significant steps in moving legislation aimed at tackling the issue of surprise billing. One bipartisan approach, H.R. 3502 sponsored by Rep. Raul Ruiz, MD (D-CA) and Rep. Phil Roe, MD (R-TN), is supported by organized medicine. AMA analysts say it addresses surprise billing in a balanced manner and encourages reasonable out-of-network billing and payment practices by resolving disputes by an independent dispute resolution process that relies on independent data, stabilizes insurer premium growth, strengthens provider networks and preserves patient access to care.
Two other bills – H.R. 3630 and S.B.1895 – championed by insurance companies, use a payment benchmark that 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. The AMA warns the benchmark could devastate physician practices by giving insurers full rate-setting authority, undermining provider networks and causing even more consolidation.
The AMA wrote in their August recess action kit that legislation that limits plan obligations to only the median rate paid to in-network physicians greatly advantage insurers by absolving them of the need to create strong networks for the provision of hospital-based and other services and protecting them from the consequences of their failure to create those networks. Regardless of their lack of effort to create an adequate network, they would enjoy federal limits on the amount they would have to pay for care.
Median in-network rates do not fairly reflect the cost of providing services by all providers nor do they capture other benefits that go hand in hand with being in-network, such as additional incentive payments as part of value-based contracts, prompt and direct payment by plans, and listing in provider directories.
“It is not reasonable, therefore, to impute that adequate rates for in-network physicians are sufficient or equitable for those that do not enjoy the additional benefits of being in network and are therefore not able to discount their rates,” the AMA said.
Terri Folk, AMA regional political director, urged physicians to speak out on this issue. “Physicians need to be communicating with their legislators now that surprise billing needs to be fixed in a way that holds insurance companies accountable while protecting patients.”
Go to physiciansgrassrootsnetwork.org/surprise-billing to learn more about the federal effort, find talking points, and connect with your legislators.
Preparing for the implementation of Colorado’s out-of-network bill: Read the CIVHC FAQ
The Colorado General Assembly passed HB 19-1174 during the 2019 legislative session to help protect Colorado patients from surprise out-of-network bills. Included in the bill are specifications regarding provider reimbursements for out-of-network emergency and non-emergency visits. The Colorado All Payer Claims Database is identified in the bill as a data source related specifically to the statewide commercial carrier median geographic payments specified in the bill, and CIVHC – the administrator of the APCD – is working collaboratively with the Division of Insurance to finalize specifics regarding the methodology that will be used and the data elements that will be available to the DOI from the CO APCD. CIVHC has compiled a “frequently asked questions” document to provide some guidance to providers. Access the FAQ at www.civhc.org.