Action Center

Out-of-Network Billing
August 6, 2019
 

Physicians Encouraged to Contact Congressmen During August Recess

 
August recess is here. For the next six weeks, members of Congress will be back in their home districts holding town halls, listening sessions, coffee-on-the-corner events, meetings with constituents and, most importantly, listening to the concerns of the people they represent.

Please take advantage of this district work period to schedule a meeting or attend a town hall with your elected officials. You can find town halls near you here: https://townhallproject.com/
 
Congress has taken significant steps in moving legislation aimed at tackling the issue of surprise billing. This culminated recently when the House Energy & Commerce Committee reported out H.R. 3630, the “No Surprises Act,” legislation designed to protect patients from unanticipated medical bills for services provided by out-of-network physicians and facilities in emergencies and other situations where they had no opportunity to choose an in-network provider. The committee’s action follows similar steps taken by the Senate Health Education, Labor and Pensions Committee last month.

KMA is urging physicians to contact their House and Senate members to request that the patient be removed from out-of-network billing disputes and to implement an independent dispute resolution (IDR) policy that supports access to care and fairness between health plans, providers and patients.

Members are encouraged to utilize these talking points in their communication:
  • The Kentucky Medical Association agrees fully with efforts to protect patients from the financial impact of unanticipated medical bills that are received through out-of-network services in an emergency or from out-of-network physicians at in in-network facility.
  • While out-of-network physicians are willing to forgo the ability to balance bill patients for amounts not covered by their patient’s insurance company, there must be a fair mechanism for settling disputes between physicians and plans over the appropriate payment amount.
  • Some congressional proposals would mandate that the plan only be required to pay the physician at the plan-specific median in-network rate.
  • Legislation which limits health plan obligations to only the median rate paid to in-network physicians greatly advantage insurers by absolving them of the need to create strong provider networks.
  • A government-mandated payment benchmark such as this is an untested formula that will harm physicians and patients alike, especially in rural areas.
  • Instead, when the minimum payment from the payer for out-of-network care is insufficient, an IDR process, similar to a New York State law, should be developed to determine a fair payment by the health insurance company for the care provided.
  • Such an IDR, or appeals, process was included in H.R. 3630, the legislation adopted by the House Committee on Energy and Commerce. While this is a positive step, Congress should continue to improve this proposal by establishing clear factors that an independent third party, familiar with health care billing, must consider when making a determination – complexity of the case, the experience of the physician, and the rate that physicians charge for that service in the area.
  • At a minimum, fair and reasonable payment should be based on actual local charges as determined through an independent claims database.
  • To protect patients from the failure of their health insurer to provide an adequate network of physicians, any federal bill should include strong and enforceable network adequacy requirements based on measurable standards. Such requirements will prevent surprise bills before they happen.
  • Benefits should be assigned to the physician or other providers so that they may pursue payment for services provided directly with the insurer without further involving the patient.
 
When Congress returns after the August recess they will continue the work on moving this issue forward and we need to be sure that physicians’ voices have been heard on this issue. Please plan your August recess activities today!
 
Contact Senator McConnell (502) 582-6304
Contact Senator Paul (270) 782-8303
Contact Congressman Comer - 1st District (270) 487-9509
Contact Congressman Guthrie - 2nd District (270) 842-9896
Contact Congressman Yarmuth - 3rd District (502) 582-5129
Contact Congressman Massie - 4th District (606) 324-9898
Contact Congressman Rogers - 5th District (606) 886-0844
Contact Congressman Barr - 6th District (859) 219-1366
 


July 15, 2019
 

KMA Leaders Travel to DC for Discussion on Surprise Billing; Members Asked to Contact Congress




Last week, KMA leaders traveled to Washington, DC to meet with members of Kentucky’s congressional delegation regarding legislation related to out-of-network or “surprise” billing.

KMA Secretary-Treasurer Bob Couch, MD, along with KMA Executive Vice President Pat Padgett and KMA Deputy Executive Vice President/Director of Advocacy Cory Meadows met with both Kentucky Senators and its six Representatives. The meetings were well-received and came at a crucial time for the legislation, as discussion has continued to intensify.

KMA is urging members to help further this work by contacting House and Senate members to request that the patient be removed from out-of-network billing disputes and to implement a New York style arbitration policy that supports access to care and fairness between health plans, providers and patients.

Members are encouraged to utilize the following talking points in their outreach:
  • The Kentucky Medical Association agrees fully with efforts to protect patients from the financial impact of unanticipated medical bills.
  • While the principal Senate and House bills adhere to this principle, these measures would only require insurers to pay the physician at the plan-specific median in-network rate. A government-mandated payment benchmark such as this is an untested formula that will harm physicians and patients alike.
  • Instead, when the minimum payment from the payer for out-of-network care is insufficient, an independent dispute resolution (IDR) process, similar to a New York State law, should be developed to determine a fair payment by the health insurance company for the care provided.
  • The IDR should be structured with clear factors that an arbiter, familiar with health care billing, must consider when deciding such as the complexity of the case, the experience of the physician, and the rate that physicians charge for that service in the area.
  • Fair and reasonable payment should be based on actual local charges as determined through an independent claims database.
  • To protect patients from the failure of their health insurer to provide an adequate network of physicians, any federal bill should include strong and enforceable network adequacy requirements based on measurable standards. Such requirements will prevent surprise bills before they happen.
  • Benefits should be assigned to the physician or other providers so that they may pursue payment for services provided directly with the insurer without further involving the patient.
Contact Senator McConnell (202) 224-2541
Contact Senator Paul (202) 224-4343
Contact Congressman Comer - 1st District (202) 225-3115
Contact Congressman Guthrie - 2nd District (202) 225-3501
Contact Congressman Yarmuth - 3rd District (202) 225-5401
Contact Congressman Massie - 4th District (202) 225-3465
Contact Congressman Rogers - 5th District (202) 225-4601
Contact Congressman Barr - 6th District (202) 225-4706

 
July 8, 2019

This message is an update to a recent KMA Legislative Alert regarding Congress’s ongoing efforts to address unanticipated medical bills, also referred to as “surprise billing.” 

On June 26, the Senate Health, Education, Labor and Pensions (HELP) Committee held a hearing on S. 1895, the Lower Health Care Costs Act.  The legislation was voted out of the HELP Committee by a vote of 20-3, with Senator Rand Paul (R-Kentucky) opposing. 

The bill positively addresses a variety of issues, including prescription drug pricing, provider network and pricing transparency, mental health and substance abuse parity, and tobacco regulation.  However, the surprise billing provisions of the bill remain problematic because they only require insurers to pay a plan-specific median in-network rate for out-of-network care. 

This untested payment formula absolves insurers from the need to create strong networks for the provision of hospital-based and other services.  It also removes a physician’s ability to negotiate, when that ability is already diminished due to the significant market power of health plans.  The result not only would be harmful for physicians but also patients, primarily due to increased health care costs and decreased access to care, particularly in rural areas where options for patients are already scarce.

KMA supports addressing out-of-network billing by implementing the only solution that has been tested and proven successful: independent dispute resolution (IDR).  This approach, modeled on a law in New York State, provides for a process whereby a neutral third party chooses between the physician charge or the plan’s initial payment amount.  Also known as “baseball style” arbitration, IDR is efficient, equitable, and encourages both parties to make reasonable offers at the outset.  Most importantly, IDR would protect patients by removing them from the middle of payment negotiations, preventing provider networks from being narrowed, and promoting transparency so that patients can better anticipate costs and coverage if they opt for out-of-network providers. 

S. 1895 could be considered on the Senate floor by the end of July.  Therefore, KMA member input is critical.  KMA is renewing its call for members to contact Sen. Mitch McConnell and Sen. Rand Paul TODAY to request that the patient be removed from out-of-network billing disputes and to implement a New York style arbitration policy that supports access to care and fairness between health plans, providers and patients.

Contact Sen. McConnell (202) 224-2541

Contact Sen. Paul (202) 224-4343


June 24, 2019

ACTION REQUESTED: Out-of-Network Billing Legislation Moving Through Congress; Vote Expected Wednesday

There are currently several pieces of legislation moving through Congress regarding out-of-network or “surprise” medical billing. While KMA is supportive of efforts to address this issue that negatively impacts both patients and physicians, the legislation gaining the most momentum contains a number of provisions that are concerning for both groups.

The Issue: Surprise billing occurs when a patient seeks care at a facility in their health plan, but is treated by a physician that is not in network. This results in the patient being sent an unanticipated out-of-network or “surprise” bill, leading to both confusion and financial turmoil.

Surprise billing also negatively impacts physicians, as health plans continue to narrow their provider networks and offer less reimbursement. The only recourse is to opt out, which results in limited access and fewer choices for patients.

With these concerns in mind, the state of New York in 2015 implemented a plan that provides both protections for patients and fair reimbursement for physicians. This model, called independent dispute resolution (IDR), removes patients from payment negotiations, increases the adequacy of provider networks, ensures providers are compensated fairly, and encourages transparency so patients can better anticipate costs and coverage if and when they opt for out-of-network providers. Fewer billing disputes go to arbitration, and patients are no longer left holding the bill. IDR is the only tested and proven solution to address out-of-network billing.

The Legislation: Last week, the Senate Health, Education, Labor and Pensions (HELP) Committee released the “Lower Health Care Costs Act,” sponsored by Sen. Lamar Alexander (R-TN) that is scheduled for a committee vote on Wednesday, June 26. 

While the bill contains several provisions that KMA would support, its solution for addressing out-of-network billing would be detrimental to patients and providers. The legislation mandates that out-of-network physicians be paid at the health plan’s “median in-network rates.” This untested process would limit access to care by reducing provider networks, particularly in rural areas where options for patients are already scarce, as health plans would have little incentive to build robust networks since payment for out-of-network care would essentially be mandated by the government. The proposal removes a physician’s ability to negotiate, when that ability is already diminished due to the significant market power of health plans. 

KMA Position: KMA supports addressing out-of-network billing by implementing the only solution that has been tested and proven successful: independent dispute resolution (IDR). This proposal, which has already been adopted by and proven effective in New York State, would protect patients by removing them from the middle of payment negotiations and prevent provider networks from being reduced. Physicians would also be compensated fairly, and transparency would be encouraged so that patients can better anticipates costs and coverage if and when they opt for out-of-network providers.

The legislation being heard by the Senate HELP Committee on Wednesday would exacerbate access to care for some of Kentucky’s most vulnerable patients and further line the pockets of insurers.

KMA physicians have already vocalized support for an IDR plan, with KMA Secretary-Treasurer Bob Couch, MD penning an op-ed in the Louisville Courier-Journal last week, and KMA President Bruce Scott, MD discussing the issue in his latest President’s Message, but additional physician input is critical.

Action: KMA is requesting that members contact Sen. Mitch McConnell and Sen. Rand Paul TODAY to request that the patient be removed from out-of-network billing disputes and to implement a New York style arbitration policy that supports access to care and fairness between health plans, providers and patients.
 
Contact Sen. McConnell (202) 224-2541

Contact Sen. Paul (202) 224-4343

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