On April 27, as part of ASA’s ongoing work related to out-of-network payment issues, ASA First Vice President James D. Grant, M.D., and Sherif Zaafran, M.D., Chair of ASA’s Ad Hoc Committee on Out-of-Network Payment, represented ASA at a meeting with leadership of the U.S. Department of Health and Human Services (HHS) in Washington, D.C. concerning the rising problems with out-of-network payment. The meeting, arranged by HHS, served as a forum for HHS leadership to elicit feedback from provider stakeholders about initiatives needed to address the topic.
The President’s HHS 2017 Budget provides that “[i]n an effort to promote transparency on price, cost, and billing for consumers, the Budget supports the standardization of billing documents and eliminating surprise out-of-network charges for privately insured patients receiving care at an in-network facility.”
Out-of-network payment, commonly termed “surprise bills” or “balance billing,” occurs when a patient receives a bill for the amount remaining between the out-of-network provider’s fee and the amount contributed by the patient’s insurer after copay and deductibles. In most cases, balance billing is the result of a large gap between what the insurer chooses to pay in an out-of-network setting and the physician’s billed charge. Per the FY 2017 Budget in Brief, “Hospitals would have to take reasonable steps to match individual patients with providers that are considered in‐network for their plan. Furthermore, all physicians who regularly provide services in hospitals would be required to accept an appropriate in‐network rate as payment‐in‐full. Thus, if the hospital failed to match a patient to an in‐network provider, the patient would still be protected from surprise out‐of‐network charges.”
Recognizing the evolving impact out-of-network payment has on the advocacy and public relations efforts of state component societies, in 2015 ASA’s Executive Committee approved an Ad Hoc Committee on Out-of-Network Payment (AHCONP) which is developing advocacy materials and providing support to states engaged in out-of-network payment initiatives. Drs. Zaafran and Grant, through AHCONP, have been working with a number of the physician stakeholder groups represented at the meeting, leading to dialogue where the medical societies were building off one another to help HHS understand the nuances and complexities of this insurance industry created problem that patients are enduring.
Dr. Grant helped the group understand that even in elective surgeries, complications and emergencies occur that sometimes require other health care professionals who may not be in-network. Dr. Zaafran highlighted the need for a Patient’s Bill of Rights, that an out-of-network deductible apply to an in-network deductible, and that insurers must have an adequate number of physicians in the plans that they sell. The Bill of Rights would outline patient rights, provide a solution for what really is an insurance gap, and advise how to know what the insurance product is as well as what is and what is not covered.
At the event, attendees shared that the challenge with this topic is as much about patients being unaware of what their plans actually covered as it is about the unexpected bill they received. As it stands, providers may know their charges but are not aware of a carrier’s payment for the health services to be rendered, especially with the complex array of different insurance products offered to consumers. As such, while patients are responsible for educating themselves on their coverage, the insurers must be made to be more forthcoming with information. Moreover, insurers should do more to educate patients that when they schedule a procedure/surgery, others - such as a physician anesthesiologist, radiologist, or pathologist - may be involved and it is important to determine their network status as well.
With the complexity of plans, the narrowing of networks and increasing use of network tiers where a provider may be in one tier and not the other, the carriers were again noted as the single source for where patients could go for such information. The group also discussed that while the media has promoted out-of-network payment as an emerging issue, the data still points to this being an important matter that impacts a very small percentage of patients. Proposed solutions to the challenge included references to states that are using an independent database of billed charges to address benchmarking for out-of-network concerns.
In addition to HHS’ consideration of out-of-network payment, legislative efforts are pending in a number of states on this subject including prohibitions on balance billing, requirements for “good faith estimates,” out-of-network disclosure/consent requirements for non-emergency services, and mediation triggered by a minimum price threshold. HHS will likely seek more information on out-of-network payment and ASA will continue to report the efforts of ASA physician leadership to educate policymakers on this important subject.
For more information, contact Jason Hansen, Director of State Affairs, at [email protected].