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Balance billing call for action

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  • Balance billing call for action

    As you might heave heard, Balance billing or “surprise billing” is quickly being resolved at the federal level. The outcome of the resolution will affect all of us deeply. Multiple committees and representatives/senators have proposed solutions to patients being left with massive out of network bills after emergencies.

    Insurance companies have used this urgency to craft legislation that will tie reimbursement for out of network care to either Medicare rates or “median” regional rates. This will effect ALL physician/np/pa reimbursement! In California a bill was passed linking these rates to Medicare as a benchmark. This has led to insurance companies dropping physicians from networks and ceasing all negotiations on rates to accept Medicare rates as the default. Eventually this would lead to all reimbursement at Medicare rates or a percentage add on to the Medicare rate.

    Please write an email to your state senator and your representative to encourage them to support the New York model for balance billing (Patient held harmless, independent board to assess regional payments, 80th percentile payment for out-of-network emergency care, baseball style arbitration for disagreements). Here is how you can find them:

    https://www.senate.gov/senators/index.htm

    https://www.house.gov/representatives/find-your-representative

    I have included at the bottom a sample letter and contact information for each of the Senators and Representatives to make it easy.

     

     

    Dear Sen. or Rep.        ,

     

    I am writing to urge you to oppose the surprise medical bill provisions of the “Lower Health Care Costs Act” that was recently introduced by Senators Alexander (R-TN) and Murray (D-WA). The Alexander-Murray provisions are completely unworkable for physicians and threaten health care delivery all over our country. Please revise these provisions to address the concerns of the physician community.

     

    As a physician practicing in          , protecting my patients from surprise medical bills is a high priority. In fact, well over 90 percent of our claims are in-network. To address those out of network services, I support holding patients harmless from additional out of pocket costs.

     

    To address billing disputes, I support a fair and independent dispute resolution mechanism — one that balances the interests of providers and insurance companies. As currently written, the Alexander-Murray proposal fundamentally reweights the health care marketplace to the benefit of insurance companies. Physician practices all over the country will suffer. Additionally, insurance companies will have no incentive to create adequate networks of providers. Therefore, the number of patients receiving heath care out of network will only increase. An example of this is seen in California where an out of network bill was linked to Medicare rates and has led to multiple insurance companies dropping physicians from their networks at alarming rates.

    Additionally, under this proposal, the federal government would set in law an unprecedented “benchmark” or payment cap in the commercial insurance marketplace. Payments to out of network physicians and other providers would be capped at the “local median contracted commercial amount” – an amount determined by and ultimately controlled by insurance companies. This misguided price setting will undermine my practice. It will also harm my colleagues’ practices in rural areas.

     

    The Senate should instead consider and advance a well-tested, successful model such as that provided by the state of New York, elements of which are included in Senator Cassidy’s and the Bipartisan Work Group’s proposal. New York provides robust patient protections that removes patients from billing disputes, so they are responsible for nothing more than their in-network copays and deductibles. It also creates an independent dispute resolution process to address billing disputes between physicians and insurers, and guides payment to a market-based, reasonable cost. The New York model has been in place since 2015 and studies indicate that it has reduced complaints related to surprise medical bills.

     

    Once again, I urge you to oppose the surprise medical bills provisions in the “Lower Heath Care Costs Act” and to instead support a re-balancing of the proposal.

     

    Sincerely,

    Dr.

    123 main st any town USA

     

  • #2
    Hopefully this doesn't get passed. Our professional society has already been on top of this, but we're pretty small compared to primary care specialties.

    Comment


    • #3
      wonder how many people here know what balance billing is.

      i wonder how many have income that will be directly affected by balance billing.

      thanks for sharing

       

       

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      • #4




        wonder how many people here know what balance billing is.

        i wonder how many have income that will be directly affected by balance billing.

        thanks for sharing

         

         
        Click to expand...


        True, some specialties are affected more than others. However it is important to help each other. You help me today, I help you tomorrow....because there is always a threat coming, no matter the specialty or the employment model.

        Comment


        • #5




          to support the New York model for balance billing
          Click to expand...


          R locations would be better served to call this "baseball style arbitration" ... anything with the words "New York model" is flatly rejected in my congressional district.?

          There are several different bills or pre-bills floating around right now.  It will be interesting to see what the consolidated form looks like.  Hopefully this will fix the shenanigans of both rogue docs as well as greedy insurers.  The self-funded plans in my state got a gift this year from the legislature while the ERISA plans seem to be taking a wait and see approach, but will likely benefit if the market is disrupted in favor of the insurers.  Time will tell.  My exit plan is in place.

          Comment


          • #6







            wonder how many people here know what balance billing is.

            i wonder how many have income that will be directly affected by balance billing.

            thanks for sharing

             

             
            Click to expand…


            True, some specialties are affected more than others. However it is important to help each other. You help me today, I help you tomorrow….because there is always a threat coming, no matter the specialty or the employment model.
            Click to expand...


            sure.  in that sense, everyone should help with this issue because ultimately collections will drive future income no matter what anyone says.  my question was more about how many are on compensation models have uncoupled income from collections (rvu or salary) in fields that would have historically been affected.  i currently am uncoupled but theoretically otherwise would be at risk, as i was for most of my career.

            many younger physicians will have always been on rvu or salary and have no idea what balance billing is.  no idea what they bill in fact.  no idea what percentage of collections they have.  etc etc

             

             

            Comment


            • #7


              many younger physicians will have always been on rvu or salary and have no idea what balance billing is.  no idea what they bill in fact.  no idea what percentage of collections they have.  etc etc
              Click to expand...


              bingo.  and since the med studs and residents don't get an education on this--and seemingly little exposure to private practice--the cycle continues.

              combine this with what I am calling an "employee mindset" not only do they not know, they don't care.

              and as a result, we get forum threads such as signing an amended contract agreement for a doc that is taking Q friggin 2 call....

              Comment


              • #8
                This legislation will be challenged in court if passed at it is currently written.

                I've been writing, emailing, and calling my Senators like crazy.  They're probably tired of hearing from me.

                Comment


                • #9
                  wait, are most folks payer contracts not expressed routinely as a percentage of medicare? Ours certainly are and that is the norm in my specialty and region. Frankly I don’t know how else we would do it. We bill literally hundreds of different codes and negotiating each would seem almost impossible and create a lot of opportunity for failed negotiations. As it stands negotiations are basically, hey we used to pay you this percent, now we want to pay you this (lower) percent, and then we counter with some percent, and we usually come to an agreement. But it’s all expressed as percent of medicare rate.

                  I would not work for medicare rates or anything close to it across the board

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                  • #10
                    Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?

                    Comment


                    • #11
                      The rate is significantly greater than the Medicare rate. In other words the contract expresses the payment as some number greater than 100%. Sometimes Medicare rates change and this is factored into negotiations with payers.

                      Comment


                      • #12




                        Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?
                        Click to expand...


                        because you don't want to negotiate every last little procedure and visit code?

                        in some ways everything is arbitrary.  we've always pegged it to medicare rates.  we've always been successful at maintaining rates above medicare levels, but there is always stress during the negotiation period.  how do you guys do it?  i'm open to learning better ways.

                         

                        Comment


                        • #13
                          Out-of-network reimbursement drives in network reimbursement.

                          Why would any insurance company contract for rates greater than Medicare if out-of-network rates will be capped at 100% of Medicare?

                          All doctors, not just those of us that treat out-of-network patients need to aggressively fight this.

                          Comment


                          • #14
                            It might be helpful to add which states already have legislation and which would benefit from representative contact?

                            Comment


                            • #15
                              Consumer point of view:
                              Medicare, insurance, copay, cash? Whatever it is should be reasonable and an arms length transaction.

                              The current balanced billing is a fiasco. Bad behavior on insurance companies and providers. Simply stated:
                              1) A large hospital system gets better reimbursement rates than the smaller groups or pp. Sometimes, competing hospital systems are played against each other.
                              2) A hospital is “in network” but outsources almost all of the services and providers and separate billings CLEARLY reflect out of network rates.
                              3) Chargemasters are useless. A patient has no idea which codes you are planning to throw in there.
                              4) SOME display signs that they accept insurance plans and credit cards. Yes, they submit, are out of network, insurance denied due to out of network. The charge additionally is way over ANY in network price. On top of that, their is a 15% markup for using a credit card. The reason is the ability of a patient to protest . No insurance, prices from heaven and stick it to the patient that has zero expertise in protesting. Mean while the provider has staff trained to handle “billing disputes”.

                              “123 main st any town USA” will NOT accept a New York solution. Period!

                              Too many games. I hear your complaint about Medicare prices. It is the “best of the worst options”
                              I hear your complaint about insurance reimbursement, it is the “second best of the worst options”. SOME physicians have ruined public trust in a physician setting fair prices.

                              Flu vaccine
                              Facility fee
                              Provider fee
                              Observation room
                              Payment method
                              Total cost
                              The games played lead to a patient being screwed without ever see a physician.

                              Up front, tell the patient or assume responsibility for the writeoff. My apologies to the great New Yorkers, it happened before and I hope you get some relief from some of the poor outcomes. Not interested in “artbitration panels or lawsuits like New York or permitting balance billing.

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