This Week in Washington DC – May 25, 2019

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.

Other
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.