Patient Support & Advocacy

Insurers are a roadblock to proven reforms on surprise medical bills

Even as health insurers have saddled patients and physicians with time-wasting prior authorization requirements that delay care and sometimes lead to serious or life-threatening events, the industry is now wrongly calling “cumbersome” a simple, proven reform that will help address the problem of surprise medical bills.

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Lawmakers, physicians, health care organizations and payers appear to agree on one thing: Patients should be held harmless and not subject to bills higher than they would expect to pay had an in-network physician been available.

The “positions diverge, however, once the overriding goal of protecting patients is addressed, with some seeking to obtain market-disrupting financial advantage through deceptive claims and advertisements,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter sent today to congressional leaders.

Physicians have proposed a proven method for resolving payment disputes that keeps patients from being caught in the middle, but the insurance industry and others have been making statements and posting political ads stating otherwise.

The U.S. House of Representatives Energy and Commerce Committee last week adopted an independent-dispute resolution (IDR) process as part of legislation known as the “No Surprises Act.” The bill copies the appeals process adopted by New York in 2014 that has successfully been used to protect consumers from out-of-network charges.

The IDR process would serve as a backstop if the federal legislation’s underlying methodology failed to arrive at a solution deemed fair by both parties. So physicians were discouraged to hear America’s Health Insurance Plans (AHIP), an insurance lobbying group, declare that an IDR process would allow providers to “price gouge patients.”

This is a complete mischaracterization of the committee’s action because the legislation says patients who receive an unanticipated out-of-network bill would not be obligated to pay anything above typical in-network charges.

Proven way to resolve pay disputes

Like New York’s statute, the bill before the House would allow an independent third party to determine whether the plan payment amount or the provider bill represents the most appropriate resolution to the claim.

A New York-style IDR was included in a set of principles on surprise billing that the AMA outlined as keys to solving the issue when Congress began to examine the issue in earnest this spring.

Dr. Madara’s letter took issue with how the Blue Cross Blue Shield Association criticized the proposed IDR process as “cumbersome.”

“To the contrary, the New York process” involves filling out a two-page online form. “This contrasts with the often-voluminous filing requirement necessary for providers to obtain prior authorization from many health plans just to provide covered benefits to their patients needing health care services and prescriptions.”

Medical community backs IDR

There is consensus in the medical community that an IDR process should be included in a legislative solution to surprise billing. A call to do so was included in a July 16 letter to Energy and Commerce Committee leaders that was signed by the AMA and 100 other medical organizations.

“Such a process should be set up to incentivize health plans to make a fair initial offer of payment for out-of-network care rendered to their customers and discourage physician bills that are outside of generally acceptable ranges,” that letter states. “It also should encourage, rather than discourage, both parties to contract for in-network care.”

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