Congress Heads Home for the Memorial Day Weekend After Busy Week on Surprise Medical Billing: How this may Impact Your Practice

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

In response to President Trump's urging, the U.S. Senate and House are active in releasing plans to end balanced-billing, or when out-of-network patients receive unexpectedly high medical bills. Various drafts and bills were released from the relevant congressional committees, including the House Energy & Commerce, House Ways & Means, and the Senate HELP committees. The House Physicians Caucus will also release a proposal. Legislation on surprise billing generally refers to situations when a patient receives a bill for unscheduled care at an out-of-network facility (i.e., emergency room visits) or an in-network facility with a physician that is not in the insurer’s network. It also applies to scheduled care at an in-network facility, but the physician is not in the insurer’s network.

The House Ways and Means Health Subcommittee on Tuesday also held a hearing on surprise medical bills. ACG is monitoring and reviewing the various drafts and working with policymakers on important issues impacting GI practices. The various proposals that have been released so far are intended to hold patients harmless and limit their financial obligations to their existing in-network cost-sharing rate, where insurers and providers have set reimbursement, along with an arbitrations process to settle any dispute. How are these reimbursement prices determined?

Establishing a payment rate benchmarked off of the average or median in-network rate in a geographic area.
Potential impact to GI practices: Physicians would likely be charged lower than normal rates. As you know, in-network rates are negotiated between insurers and providers. Providers typically receive a lower rate in exchange for access to patients. If in-network rates are averaged, physicians may receive considerably lower than market rates for their services. Further, rural providers could be dis-proportionally impacted because geographic bench-marking may limit their ability to negotiate with insurers. For example, if the insurer can charge an average in-network rate, that would be lower than a directly negotiated rate, thus there may little incentive for the plan to contract with the provider.

Establishing a payment rate based on Medicare rates.
Potential impact to GI practices: Depending on the area and commercial contracts, the Medicare rate would be typically lower than the payment the physician would otherwise receive. Providers usually rely on offsetting Medicare rates with commercial insurer payments. This could impact providers that have many Medicare/Medicaid patients.

Establishing a “baseball style” arbitration method
This was a popular phrase being thrown around the Hill this week. A “baseball style” arbitration is where a plan and a provider each propose a payment, and the arbitrator selects one of the rates. Typically, the losing party must cover the costs of arbitration. Obviously, the phrase is derived from the process that Major League Baseball uses to settle salary disputes.

Potential impact to GI practices: The arbitration approach could cause uncertainty in payments, especially if the losing party must pay for the arbitration costs. However, depending on the factors that arbitrators must weigh to determine a “fair” payment, the arbitration-style model could result in favorable decisions for providers.

The proposals also include provisions to improve transparency by establishing claims databases to better understand health costs. There are also ideas to force providers to obtain patient consent before the patient is transferred to a provider that is out-of-network. Additionally, providers will be responsible for determining whether a patient is in-network prior to treating the patient.

Potential impact to GI practices: These proposals could lead to added physician burden. Physicians may not be able to obtain consent, limiting the patient’s access to care. Physicians also may not be reimbursed for the time spent determining whether or not the patient is in-network. This will lead to further administrative delays, physician burnout, and lost revenue.

Next steps
ACG is monitoring these issues as Congress and the Trump administration work through the process of getting a final proposal. ACG is also working with congressional leaders and staff on other areas where a patient incurs an unexpected cost, surprise bills, and in other areas of patient care such as outpatient GI procedures and out-of-network ancillary services associated with these procedures.

Speaking of Surprise Billing: Urge Congress to Support the Removing Barriers to Colorectal Cancer Screening Act of 2019

At the State and Local Level: Surprise Billing Ban Moves Forward in Texas

From the ACG Governors from Texas:

Texas state representatives unanimously approved a bill that bans providers from sending patients a surprise bill for emergency services, as well as certain out-of-network ancillary services. Senate Bill 1264 passed the Texas House on a 146-0 vote but only applies to state-regulated insurance plans.

The bill would create an arbitration process allowing some providers and insurers to negotiate final payment amounts. The Texas Senate passed different version of the bill in April. Thus, the two chambers need to concur on House amendments before the bill goes to Governor Greg Abbott.

Northern Texas Governor Jay Yepuri, MD, MS, FACG

Southern Texas Governor Harish K. Gagneja, MD, FACG


The ACG Board of Governors is one of the most unique aspects of the American College of Gastroenterology. Governors are ACG Fellows that are elected from the membership of a particular state or region. There are currently 77 Governors across seven different regions in the U.S. and abroad. The Board of Governors acts as a two-way conduit between College leadership and the membership at-large. This helps the College make certain it is meeting the evolving needs of the membership.

FDA Update: FDA Clears a Modified Endoscope Port Connector Designed to Help Reduce the Risk of Cross-Contamination

From ACG's FDA Committee Chair Steve Hanauer, MD, FACG:

FDA Clears a Modified Endoscope Port Connector Designed to Reduce the Risk of Cross-Contamination
The FDA’s clearance of the modified ERBEFLO 24-hour use port connector is based on the agency review of the functional and simulated use testing of the modified device design. The effectiveness of the Erbe system (the ERBEFLO 24-hour use port connector and Erbe irrigation tubing) at reducing the risk of backflow and contamination of the irrigation system is supported by simulated use testing, as recommended in the FDA guidance.

The revised labeling identifies compatible endoscopes and accessories, as the FDA guidance recommends, by specifying that the modified ERBEFLO 24-hour use port connector should only be used with Erbe irrigation tubing. In addition, clear and specific new warnings help assure proper use of the device.

For example, the revised labeling:
Warns against disrupting the irrigation pathway during a clinical procedure by disconnecting the port connector from the endoscope or the irrigation tubing while the scope is inside a patient, and warns against connecting the port connector to an endoscope once the scope is inside a patient.

ACG and the FDA Related Matters Committee will continue to update ACG members with important FDA announcements impacting clinical gastroenterology and patient care.