An AMA
letter draws renewed attention on legislative fixes for surprise medical
billing.
By Sara Heath
October 22, 2019
- The American Medical Association (AMA) is looking for a balanced answer to surprise
medical billing after the industry has seen a slowdown in legislation aimed to
address high out-of-pocket patient costs.
In a letter signed by 101 medical societies,
the AMA called on Senate leaders Mitch McConnel (R-KY) and Chuck Schumer (R-NY)
to lead their chamber to a consensus on surprise medical bills.
“We strongly believe
that, in situations where a coverage gap occurs and patients unknowingly or
without a choice receive care from an out-of-network physician or other
provider, patients should be held harmless for any costs above their in-network
cost-sharing, and their cost-sharing should count toward deductibles and
out-of-pocket maximums,” the groups wrote. “Patients should be completely
removed from any subsequent payment disputes between their health insurance
company and an out-of-network provider when they experience an unanticipated
coverage gap.”
Specifically, the
groups are calling on Congress to pass legislation that would prevent staffing
shortages at hospitals, noting that certain proposals that are “tilted toward
insurers” would cause undue harm on hospital and physician office finances.
Charging the median
in-network rate in the event of a surprise medical bill, for example, would
cut reimbursement rates for hospitals across the country and hamper smaller
hospitals’ abilities to maintain adequate workforce. This, in turn, could put
patient care access in danger.
Instead, AMA and
co-signatories recommend a wholly independent dispute resolution (IDR) process
to be espoused in legislation.
This process would be
more balanced, the letter states, because it would protect patients from
surprise medical bills while preserving adequate staffing and care access. The
IDR process would also create incentives for payers and providers to
collaborate on what AMA says would be a fair reimbursement rate.
“The IDR process
should be structured so that a range of factors is considered in determining a
mutually fair payment—such as the complexity of the service rendered, the
experience of the physician providing the service, the rate that physicians or
other providers charge for the service in a geographic area, and insurance data
from an independent and transparent source,” the letter states.
The letter also makes
a nod to current entities that leverage an IDR solution to surprise medical
bills, most famously in New York. The state’s “baseball style” arbitration
process has resulted in a 34 percent cut in out-of-network billing, a 9 percent
reduction in physician reimbursement, and over $400 million in patient savings
for emergency care.
AMA and colleagues
continued by addressing payer concerns that an IDR process would be too
cumbersome because of the two-page administrative form required to participate
in New York’s arbitration process.
“This contrasts with
the often voluminous filing requirements necessary for physicians and other
providers to obtain prior authorization from many health insurance companies
just to provide covered benefits to their patients, even for mental health and
substance use disorder treatments,” AMA and colleagues pointed out.
This letter comes as
the health policy world has seen a slowdown in debate over surprise medical
bills.
Discussions came to a
head this past summer, as Congressional leaders across the country proposed
their own bills to address surprise billing leveraging one of two main ideas:
rate-setting and IDR processes.
Most prominently, the
Lower Health Care Costs Act initially
proposed a debate to determine the best solution for surprise billing, and
after a series of hearings embraced the rate-setting strategy. The bill, if
passed, would call for a set reimbursement rate.
But talks of any bill
addressing surprise medical bill have since gone quiet, with news reports
pointing to major lobbying groups working to tamp down on the bills.
Significant advertising campaigns have worked to warn the public on what it
calls the risks of a set reimbursement rate, potentially keeping some
Congressional leaders from taking up a vote on the matter.
The jury is still out
whether this latest AMA letter will spark renewed discussions about surprise
medical billing.
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