OON billing/recent legislative efforts

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Physician, hospital groups gear up for fight on surprise medical bills

Congressional committees want to put limits on doctor pay for out-of-network care as they look to crack down on surprise medical billing practices. Provider groups want their prices to stay fluid.

www.modernhealthcare.com

Trying to educate myself on proposed federal legislation to limit OON billing and what it means for groups like mine (smaller groups who are virtually always in network). It seems to me the loudest opponents to restraints on OON billing are AMCs/management companies for ER/radiology like USAP, Envision, TeamHealth, etc who routinely use OON billing to generate revenue.

What about groups like mine who don’t engage in this practice? Is the concern that if you eliminate the leverage from going OON that you will see the negotiated in network rates drop? Is this a real concern that you guys share? How do you see this playing out?

The most concerning elements of the proposed legislation to me tie OON reimbursement to 133% of Medicare reimbursement (IF that became the standard reimbursement rate for in network commercial payers, it would amount to a 60-70% paycut for my group).

 

[Mikkel]

It's 100% a real concern. Going out of network is the only remedy for an insurer who wants to rip off docs.

It's government price fixing, plain and simple.

The pricing process needs mediation, not government fiat.

 

[Endee]

It hurts everybody because the median in network rate will drop over time. With this legislation, anyone with a contracted rate above the median in-network rate can be kicked out of network because the insurance companies would only have to pay out of network people the median in network rate. Then, the median in-network rate drops because the people that were above the median are now paid the lower median. Over time, the median in-network rate keeps dropping, until the median in-network rate becomes the Medicare rate.

It's 100% stacked in favor of the insurance companies to very quickly drive down reimbursement by just refusing to negotiate a contract. They can pay less with people being out of network. The Ruiz-Roe bill (the OONB legislation supported by ASA) includes both an arbitration policy and ties the benchmark to an independent database like FairHealth.

 

[Mman]

as noted, removing the threat of going OON means the insurance company can just low ball you every time you negotiate a new contract rate and soon your commercial rates will all be the same as CMS.

Insurance companies argue they can pass those savings on to the consumer, yet they will just pocket it as profit margin.

 

[lane]

USAP is 95% in network, and strongly favors an arbitration model along with language that would tie any OON to previously negotiated rates (so they couldn’t just drop a provider and then pay them cms adjusted rates)