ASA Says “No” to Medicare as a Benchmark for Out of Network Payments

On September 7, ASA joined several physician organizations in a formal communication to provide feedback on the Centers for Medicare and Medicaid Services' (CMS) request for information on price transparency. The communication stressed that Medicare should not be used as a benchmark for reimbursement of out-of-network providers. It also recommended that “the best measure of standard charges is the usual and customary physician charge (“U&C charge”) procured from a not-for-profit, independently owned and operated entity.”

The CMS request for information provided in part, CMS’ concerns that “challenges continue to exist for patients due to insufficient price transparency. Such challenges include patients being surprised by out-of-network bills for hospital-based physicians, such as anesthesiologists and radiologists, who provide services at in-network hospitals, and patients being surprised by facility fees and physician fees for emergency room visits.”

Out-of-network payment, also commonly termed “surprise bills” or “balance billing” is a high-level issue of concern for ASA, state component societies, large group practice entities, and a growing number of stakeholders including medical specialty organizations, insurers, patients and consumer groups, and others. Out-of-network payment 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 and the physician’s billed charge.  Indeed, ASA believes a more accurate term for the occurrence is “surprise insurance gaps.”

The coalition's letter answered CMS' five main questions, including how physicians, CMS, and insurers can better assist consumers in making the best choice for their health and safety:

We believe that it is the responsibility of payers, including CMS, to clearly provide information to consumers about the potential costs of seeking care under their particular coverage. Clinicians can participate by helping patients interpret or help decipher, as best they can, their patients' cost-sharing responsibilities, particularly in- and out-of-network out-of-pocket costs, but ultimately, the onus should be on insurers to make these costs transparent to patients. Hospital based clinicians often are not aware of the patient’s particular insurance terms and conditions, secondary or tertiary insurance, or the carriers’ policy on coordination of benefits.

Other groups who joined the communication included the American College of Emergency Physicians, the American College of Radiology, and the American Society of Plastic Surgeons. For additional information about out-of-network payment, please contact [email protected].