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(1/17)
Today’s surprise billing fix is a huge win for consumers!
As of 1/1/2022, it will be illegal nationwide for an out-of-network provider to surprise bill a patient for more than their standard in-network cost-sharing obligations.
THREAD based on the final language https://twitter.com/larry_levitt/status/1341097536866508802
Today’s surprise billing fix is a huge win for consumers!
As of 1/1/2022, it will be illegal nationwide for an out-of-network provider to surprise bill a patient for more than their standard in-network cost-sharing obligations.
THREAD based on the final language https://twitter.com/larry_levitt/status/1341097536866508802
(2/17)
The protections from surprise billing will apply in all emergency situations (w/ lone exception of ground ambulance rides) & for non-emergency out-of-network physician services received at in-network facilities.
Helpful rundown of the protections: https://www.healthaffairs.org/do/10.1377/hblog20201217.247010/full/
The protections from surprise billing will apply in all emergency situations (w/ lone exception of ground ambulance rides) & for non-emergency out-of-network physician services received at in-network facilities.
Helpful rundown of the protections: https://www.healthaffairs.org/do/10.1377/hblog20201217.247010/full/
(3/17)
These are arguably broader than the protections in any state law and will be difficult to game.
Patients can now feel safe they won't get a surprise bill from the emergency room or from an anesthesiologist or assistant surgeon involved in their elective surgery.
These are arguably broader than the protections in any state law and will be difficult to game.
Patients can now feel safe they won't get a surprise bill from the emergency room or from an anesthesiologist or assistant surgeon involved in their elective surgery.
(4/17)
With surprise billing eliminated, so to disappears the leverage exploited by several large provider groups to extract higher payment rates that meant we all paid higher premiums. https://theconversation.com/surprise-medical-bills-increase-costs-for-everyone-not-just-for-the-people-who-get-them-146476
With surprise billing eliminated, so to disappears the leverage exploited by several large provider groups to extract higher payment rates that meant we all paid higher premiums. https://theconversation.com/surprise-medical-bills-increase-costs-for-everyone-not-just-for-the-people-who-get-them-146476
(5/17)
An ideal solution might have just left things there (see https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/05/23/network-matching-an-attractive-solution-to-surprise-billing/), but the legislation also includes a new price support to be determined through an arbitration process.
However, some key guardrails should really limit the potential inflationary effects.
An ideal solution might have just left things there (see https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/05/23/network-matching-an-attractive-solution-to-surprise-billing/), but the legislation also includes a new price support to be determined through an arbitration process.
However, some key guardrails should really limit the potential inflationary effects.
(6/17)
1. Like previous iterations of fed'l surprise billing legislation, arbiters are told to base decisions mainly on median in-network rates as of 2019, inflated forward.
2. Public reporting of outcomes limits the potential for provider groups to capture the process.
1. Like previous iterations of fed'l surprise billing legislation, arbiters are told to base decisions mainly on median in-network rates as of 2019, inflated forward.
2. Public reporting of outcomes limits the potential for provider groups to capture the process.
(7/17)
3. Providers have to wait 90 days between filing arbitration claims, making it near-impossible to rely solely on arbitration for out-of-network revenue.
4. Arbiters are prohibited from considering unilaterally-set provider charges ( https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/12/05/provider-charges-relative-to-medicare-rates-2012-2017/)
3. Providers have to wait 90 days between filing arbitration claims, making it near-impossible to rely solely on arbitration for out-of-network revenue.
4. Arbiters are prohibited from considering unilaterally-set provider charges ( https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/12/05/provider-charges-relative-to-medicare-rates-2012-2017/)
(8/17)
With those guardrails in place, it's possible the final legislation actually ends up being more consumer-friendly than prior iterations.
With those guardrails in place, it's possible the final legislation actually ends up being more consumer-friendly than prior iterations.
(9/17)
Biggest risk is that arbiters give weight to previously contracted rates buoyed by surprise billing leverage (one factor in their guidance), but I'm skeptical this receives much weight. Moreover, the guardrails should limit inflationary effects even from generous awards.
Biggest risk is that arbiters give weight to previously contracted rates buoyed by surprise billing leverage (one factor in their guidance), but I'm skeptical this receives much weight. Moreover, the guardrails should limit inflationary effects even from generous awards.
(10/17)
I don’t think the addition of prohibiting consideration of Medicare/Medicaid rates should have much of an effect one way or the other (the arbiter was never going to consider those rates anyway in making determinations). https://twitter.com/LorenAdler/status/1340821886318632962
I don’t think the addition of prohibiting consideration of Medicare/Medicaid rates should have much of an effect one way or the other (the arbiter was never going to consider those rates anyway in making determinations). https://twitter.com/LorenAdler/status/1340821886318632962
(11/17)
And providers can feel secure that payment rates will only go down if current rates were buoyed upward by leverage associated with the ability to surprise bill (& commensurately so).
Facilities still need EM docs & anesthesiologists, and vice versa.
And providers can feel secure that payment rates will only go down if current rates were buoyed upward by leverage associated with the ability to surprise bill (& commensurately so).
Facilities still need EM docs & anesthesiologists, and vice versa.
(12/17)
While the bill doesn't supersede state laws regulating fully-insured plan enrollees (~half the mrkt), it seems ridiculous for states to maintain a separate arbitration process (& providers generally don't even know if a patient is in a fully- or self-insured plan).
While the bill doesn't supersede state laws regulating fully-insured plan enrollees (~half the mrkt), it seems ridiculous for states to maintain a separate arbitration process (& providers generally don't even know if a patient is in a fully- or self-insured plan).
(13/17)
The federal law also offers an easy opportunity for states with less consumer-friendly laws like NY & NJ to help their residents by glomming onto the federal approach. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/10/24/experience-with-new-yorks-arbitration-process-for-surprise-out-of-network-bills/
The federal law also offers an easy opportunity for states with less consumer-friendly laws like NY & NJ to help their residents by glomming onto the federal approach. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/10/24/experience-with-new-yorks-arbitration-process-for-surprise-out-of-network-bills/
(14/17)
Rulemaking on calculating median in-network rates is due 7/1/21, so attention will turn now to implementation. This will be toughest for air ambulances, where only 20% of rides are in-network today. https://www.milbank.org/quarterly/articles/out%E2%80%90of%E2%80%90network-air-ambulance-bills-prevalence-magnitude-and-policy-solutions/
Rulemaking on calculating median in-network rates is due 7/1/21, so attention will turn now to implementation. This will be toughest for air ambulances, where only 20% of rides are in-network today. https://www.milbank.org/quarterly/articles/out%E2%80%90of%E2%80%90network-air-ambulance-bills-prevalence-magnitude-and-policy-solutions/
(15/17)
And it’s unfortunate that ground ambulances were left out of the fix. There’s no particular reason for this omission, so hopefully lawmakers will continue working on a solution here (and we’ll have a lot more on the topic next year).
And it’s unfortunate that ground ambulances were left out of the fix. There’s no particular reason for this omission, so hopefully lawmakers will continue working on a solution here (and we’ll have a lot more on the topic next year).
(16/17)
At the end of the day, today's legislation puts an end to a market failure that was being exploited by private equity & some other large groups in a manner that should reduce health care costs overall.
That’s a clear win in my book.
At the end of the day, today's legislation puts an end to a market failure that was being exploited by private equity & some other large groups in a manner that should reduce health care costs overall.
That’s a clear win in my book.
(17/17)
And selfishly I'm excited never to have to worry about a surprise bill again when I go to the hospital.
And selfishly I'm excited never to have to worry about a surprise bill again when I go to the hospital.
