Chester County Medicine Fall 2019 - 25

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ISSUE SPOTLIGHT

Surprise medical bills:
Physicians want
market-based fixes

he AMA and 110 other
organizations representing
hundreds of thousands of
American physicians have signed
onto a letter urging Congress to
refine surprise billing legislation to
ensure the final version targeting
unanticipated out-of-network care
"represents a fair, market-based approach that treats all stakeholders
equally while protecting patient
access to care."
There are instances when unanticipated coverage gaps happen "and
patients unknowingly or without a
choice receive care from an out-of-network physician or other provider."
In those cases, the physicians' letter says, "patients should be held
harmless for any costs above their in-network cost-sharing, and their
cost-sharing should count toward deductibles and out-of-pocket maximums. Patients should be completely removed from any subsequent
payment disputes between their health insurance company and an
out-of-network provider when they experience an unanticipated
coverage gap," says the letter, sent Oct. 15 to Congressional leaders
and broadly shared with members of the U.S. House and Senate.
However, "rate-setting provisions in current bills further shift
marketplace leverage to health insurers at the expense of providers."
That "will likely lead to access problems for patients seeking hospital-based care from on-call specialists, as well as precipitate staffing
shortages in rural areas and other underserved communities."
More than 80% of the budgetary impact of the rate-setting
mechanism in the "Lower Health Care Costs Act" (S. 1895) "would
arise from changes to in-network payment rates," according to the
analysis conducted by the Congressional Budget Office, which
reached a similar conclusion regarding another bill, the "No Surprises
Act" (H.R. 2328).

The end result? "In-network
providers who have not contributed to the problem will bear the
impact of the rate-setting scheme,"
says the letter sent by the AMA and
the other physician organizations.
Physicians point to the success
that New York state has had with
a law mandating an independent
dispute-resolution (IDR) process
to deal with medical bills arising
from unanticipated out-of-network
care. New York patients have saved
$400 million-plus on emergency
care alone and out-of-network
billing has fallen 34% since 2015, according to New York State
Department of Financial Services Supervisor Linda Lacewell.
The AMA and the other physician organizations signing onto
the letter recommend specific fixes to the "No Surprises Act" to:
* Lower the $1,250 threshold to trigger an appeals process.
* Allow for IDR batching of claims involving identical plans and
providers, and the same or similar procedures that happen within
a reasonable time frame.
* Change the initial payment to reflect a commercially reasonable rate based on actual local charges determined through an
independent claims database.
* Establish measurable and enforceable network adequacy
requirements.
Congress is expected to act in the coming months.

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Chester County Medicine Fall 2019

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