Update on Surprise Billing: ACG and Coalition of Societies Urging Changes to Proposals

From ACG Legislative and Public Policy Council Chair, Whitfield L. Knapple, MD, FACG

Back in May, ACG provided some background on the “surprise billing” legislation that is currently making its way through the legislative process, and potential impact to GI practices. The legislation is designed to curb balanced billing and help settle disputes between out-of-network providers and insurers.

There are versions making its way through the U.S. Senate and U.S. House. The U.S. Senate's Health, Education, Labor, and Pensions (HELP) Committee recently cleared a bill that resolves payment disputes by paying plans and providers at a federal benchmark set to the median in-network rate for each area of the country.

CBO: A “benchmark” resolution saves the federal government money

The Congressional Budget Office (CBO) is tasked with “scoring” a bill, or estimating the costs/savings to the federal government if the bill were enacted. The provision ending surprise medical bills by instituting a federal benchmark payment would save nearly $24.8 billion over 10 years, offsetting other federal spending contained in the HELP committee's bill. According to the CBO, there would be lower federal subsidies for insurance purchased through the ACA regulated health insurance plans and from lower premiums for employment-based insurance. Here’s what the CBO had to say:

  • Premiums would be just over 1% lower than they are projected to be under current law. The decline in premiums would occur because the bill requires insurers to reimburse out-of-network providers on the basis of their own median rates for in-network providers. Median rates are generally lower than the current overall average rates.
  • Payment rates would move toward the median and that insurers’ payments to providers currently commanding in-network rates well above the median would drop to more typical amounts. The decrease in premiums resulting from lower payment rates would be offset somewhat by increases in rates for providers that now receive below-median payments.
  • Lower premiums also would be offset somewhat by increased costs for insurers to cover out-of-network care that they do not cover under current law (such as laboratory fees for out-of-network, non-emergency services).
  • There would be a small decrease in the number of people who claim the itemized medical tax deduction, which would increase federal revenues.

The CBO also noted that the legislation may shift costs in a way that could lead to consolidation of providers.

What are the risks of a “benchmark” resolution?
Since the benchmark would save the federal government costs over the next decade, it should come as no surprise that savings may be from lower provider reimbursement. A median-rate benchmark for out-of-network providers provides little incentive for insurers to agree to rates above the median-rate when negotiating contracts with participating or in-network providers. This ultimately makes the median-rate lower and lower.

What is ACG doing for you?
ACG and coalition of national and state medical societies are advocating for a system modeled after New York’s state law, which includes an independent dispute resolution (IDR) process should providers and insurers fail to agree on a payment rate.A recent report on the NY law suggest the IDR process is an equitable process: “As of October 2018, IDR decisions have been roughly evenly split between providers and payers, with 618 disputes decided in favor of the health plan and 561 decided in favor of the provider. However, insurers have tended to win the majority of out-of-network emergency services disputes (534-289), while providers have won the majority of surprise bill disputes (272-84).” The NY law advises mediators to consider the “usual and customary rate” for a service, defined as the 80th percentile of all (non-discounted) charges for a particular health care service performed by a provider in the same or similar specialty within the same geographic area.

What are the risks in arbitration?
ACG is aware, however, that going to arbitration each time there is a payment dispute is costly and burdensome for many GI practices and members. The losing party also has to pay for the arbitration costs of the winning party.

House Energy & Commerce Committee agrees to add limited IDR process
This week, the U.S. House Energy and Commerce Committee cleared their version of “surprise billing” legislation, which includes an IDR amendment offered by Rep. Raul Ruiz, MD (D-CA) and Rep. Larry Bucshon, MD (R-IN). However, IDR appeals would be restricted to cases with a claims threshold of $1,250 (indexed to inflation). The mediator must consider contracted rate for services provided in the same geographic area when resolving a payment dispute, the complexity of the patient's treatment, quality measures, and the provider's training, education and experience. The threshold is designed to limit the number of appeals. The provision also retains a higher level of savings of the entire bill (which includes other federal spending).

Next Steps
ACG continues to work with policymakers and this coalition of medical societies on your behalf. The proposals are fluid and can certainly change as Congress heads home for its August recess. For example, the Senate HELP Committee is still working with Sen. Bill Cassidy, MD (R-LA) on a proposal to include an arbitration process in the Senate version. Also, influential organizations pulled their support for the Energy & Commerce legislation once this IDR language was agreed to in the final package.

ACG is fighting on your behalf. Stay tuned!

MACRA Tidbit for the Week: CMS Release CY 2018 QPP Participation Data; Meager Bonuses Slated from CY 2020?

Last week, CMS released preliminary data for 2018 MIPS participation rates. How does 2018 stack up versus 2017?

2017 2018
Total clinicians receiving a MIPS adjustment (bonus, neutral, or cut) 1,057,823 916,058
Percent of clinician above performance threshold (eligible for bonus) 90% 96%
Percent of clinician below the performance (payment cut) 7% 3%

MIPS Participation Decreases: Less people participated in MIPS overall in 2018. One reason may be because CMS increased the “eligibility threshold” in 2018 (requiring you to participate in MIPS) for certain small and rural practices. ACG supported this, as the 2017 data showed that small practices were impacted by payment cuts significantly more than other practices. From CMS’ 2017 data: 19% of small providers, and 6% of rural providers, were hit with payment cuts this year (CY 2017 reporting year impacts CY 2019 reimbursement).

Clinicians would be EXEMPT from MIPS reporting requirements if you met one or both of the following:

Comparison of CMS’ “low volume eligibility requirements (2017-2019).

2017 2018 2019
Medicare Part B allowed charges that are less than or equal $30,000 $90,000 $90,000
Medicare Part B patients were less than or equal to 100 200 200
Medicare professional services less than or equal to NA NA 200

CMS did note, however, that despite not having to participate, many small practices chose to do so anyway. CMS touts the increases in low-volume thresholds for this voluntary participation.

APM Participation Increases: More clinicians also participated in approved alternative payment models (APMs), instead of participating in MIPS:

2017 2018
Qualifying APM Participants 99,076 183,306

CMS did not release payment data for CY 2018: In 2017, an estimated 93% were eligible for a payment bonus (or did not get cut). Of note, however, the highest payment adjustment applied in the 2019 Medicare payment year was an 1.88% bonus. What’s more, this 1.88% bonus included the “exceptional performance” bonus. MIPS-eligible clinicians who did not receive an additional adjustment for exceptional performance (i.e. had a final score of 3.01 to 69.99 points) received a meager 0.20% bonus in 2019.

What does that mean for CY 2020 payment data? ACG’s very first “MACRA tidbit for the week” in 2016 discussed the potential problems with MIPS and whether there was actually an opportunity to receive the bonuses that were marketed by CMS and policymakers. The tidbit was called "MIPS or The Other Guy Must Fall First" Payment System." Thus, if more clinicians successfully participated in MIPS in 2018 versus 2017, then successful clinicians may see EVEN SMALLER BONUSES in CY 2020. ACG will update you as CMS increases more 2018 participation and payment data.

How can ACG help you? ACG's goal is to provide membership with educational guidance in a simple, easy-to-understand fashion. We compiled a detailed overview for you that seeks to make some sense out of this alphabet soup, including acronyms such as MACRA, QPP, MIPS, APMs, etc. – but hopefully in a simplified fashion and in plain English.

ACG’s “Making $ense of MACRA” provides practical guidance for GI practices and steps you can take to be eligible for any bonus payment, as well as ways to simply avoid a payment cut. For example, participation in GIQuIC can help put you on the right track to avoid looming (and increasing) payment cuts as well as in line for any potential bonus.

What is the Practice Management toolbox?

Gastroenterologists in private practice find themselves working in a time of unprecedented transformation. Pressures are high as they make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients. The ACG Practice Management Committee has a mission to bring practicing colleagues together to explore solutions to overcome management challenges, to improve operations, enhance productivity, and support physician leadership. It was in this spirit that the Practice Management Toolbox was created.

The Toolbox is a series of short articles, written by practicing gastroenterologists, that provide members with easily accessible information to improve their practices. Each article covers an issue important to private practice gastroenterologists and physician-lead clinical practices. They include a brief introduction, a topic overview, specific suggestions, helpful examples and a list of resources or references. Each month a new edition of the Toolbox will be released and will then remain available here along with all previous editions. The Practice Management Committee is confident this series will a provide valuable resource for members striving to optimize their practices.