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'Network Matching' Offers Surprise Billing Solution

Analysis  |  By Alexandra Wilson Pecci  
   May 31, 2019

Requiring across-the-board health plan contracting from providers would eliminate most out-of-network billing, researchers say.

One solution for curbing out-of-network billing? Eliminating the possibility that a provider might be out of network in the first place.

This solution is called “network matching” or an “in-network guarantee," and would require "emergency and ancillary physicians to contract with all the same health plans as the facility in which they practice," according to Loren Adler, associate director for the USC-Brookings Schaeffer Initiative for Health Policy.

Adler, along with Benedic Ippolito of the American Enterprise Institute and Matt Fiedler of the USC-Brookings Schaeffer Initiative for Health Policy, co-authored a piece for Health Affairs proposing network matching as a surprise billing solution.

"[T]he network matching approach would directly eliminate the current market failure that allows surprise out-of-network billing, leaving physician payment rates for these specialties to be negotiated between physician, hospital, and insurer in a more normal market negotiation," Adler said via email.

"Not only would the network matching approach eliminate surprise bills, but it could significantly lower premiums and health care costs, benefitting many more people."

Network matching was also among the solutions included in Senate Health, Education, Labor and Pensions (HELP) Committee discussion draft last week.

The discussion draft suggests an in-network guarantee where "each health care practitioner who provides services in the facility will be under contract as a participating health care practitioner with respect to the plan or coverage with repect to all services provided at such facility."

Christopher Garmon, who co-authored a study showing how surprise out-of-network bills can drive patients to competing hospitals, suggested this kind of ultimatum when HealthLeaders spoke with him earlier this year.

"If you want to practice in my hospital … then you have to make a good-faith effort to be in network for all the health plans … so [we're] aligned," he said.

Adler, Ippolito, and Fiedler's Health Affairs piece notes that in order for a network matching requirement to work, it should "apply to facility-based services where patients lack meaningful choice of providers" including emergency and ancillary clinicians and out-of-network lab or imaging services referred from an in-network facility.

They also propose an exception "if the out-of-network clinician provides sufficient advance notice of their network status and estimated costs and obtains patient consent."

However, network matching has its limitations, namely out-of-network facilities and ambulances, the authors write.

Arbitration, bundling, and fixed rates were among the solutions debated last week at a House Ways and Means Health Subcommittee hearing  about protecting patients from surprise medical bills. 

Alexandra Wilson Pecci is an editor for HealthLeaders.

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