Providers are still unhappy with the government's final rule regarding the No Surprises Act's independent dispute resolution (IDR) process.
Provider groups are once taking aim at the arbitration process under the No Surprises Act, expressing dissatisfaction with the government's rewritten final rule.
The Texas Medical Association (TMA), Tyler Regional Hospital, and a physician filed a new lawsuit in the United States District Court for the Eastern District of Texas, arguing that the final rule still gives health insurers an unfair advantage over providers in the IDR process.
Meanwhile, the American Hospital Association (AHA) and the American Medical Association (AMA) stated they would file an amicus brief in support of the lawsuit.
Under the No Surprises Act, patients are protected from unexpected bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities. The law has an arbitration process when providers and insurers disagree on the charged rates.
After the government released the interim final rule in 2021, TMA filed a lawsuit challenging it, alleging that IDR process unlawfully required arbitrators to consider the insurer-calculated qualifying payment amount (QPA) as the primary factor in deciding between the provider or payer rate.
A federal judge ruled in favor of TMA in February, striking down the piece of arbitration process, which HHS appealed in April before requesting a hold on its appeal.
CMS then released a revised interim final rule in August, but TMA claims the new rule is simply rewritten from the previous one and continues to give insurer an advantage by requiring the arbitrator to consider the QPA first and foremost.
"This is unfair to physicians and the patients we care for, so we had to seek a fairer process. There should be a level playing field for physicians in payment disputes after they’ve cared for patients," TMA president Gary Floyd said in a statement.
"TMA was hopeful the federal agencies would write final rules fair to everyone, especially after the federal district court ruled the agencies’ previously challenged rules were unlawful. Unfortunately, the federal agencies returned with a plan tipping scales in health plans' favor once again," he added.
The AHA and AMA had their own lawsuit against the government's September 2021 interim final rule, but moved to dismiss the challenge after the revised final rule was released in August. Now, they will move forward with the amicus brief as they continue their fight.
"The Texas court previously held that the interim final rule impermissibly rewrote clear statutory terms by placing a thumb on the scale in favor of commercial insurers," The AHA and AMA said in a joint statement. "The final rule suffers from the same problems. As was the case with the previous suit, the AHA and AMA want to see the law's core patient protections move forward and seek only to bring the regulations in line with the law."
Analysis of price transparency data suggests better information on health insurance exchange plans (HIX) is needed.
Payers generally negotiate lower amounts for HIX plans than their commercial group rates and significantly more than their Medicare Advantage (MA) contracts at the same hospital, according to a study published in The American Journal of Managed Care.
Researchers at the University of Southern California (USC) Schaeffer Center compared price transparency data of 25 common inpatient services and 56 common outpatient services across hospital-insurer pairings and found stark differences in allowed amounts.
The 16 insurers in the study with both HIX and commercial group plans paid providers for their HIX enrollees 88.6% of their commercial group rate for inpatient services and 88.9% for outpatient services.
The 19 insurers with both HIX and MA plans paid providers for HIX enrollees 143.3% of their MA enrollees for inpatient services and 243.6% for outpatient services.
The authors attribute the price discrepancy to a few factors such as narrow network plan design and hospitals' willingness to accept lower rates for HIX plans to recoup on bills that may otherwise go unpaid due to the lower income level of HIX enrollees.
"Although hospitals receive lower reimbursement for HIX enrollees than other commercial plan enrollees, the HIX plan payment level is still preferable to the uncompensated care burden hospitals faced before the Affordable Care Act established the HIXs," the report states.
Additionally, the study's findings also back up the rulemaking in the No Surprises Act related to calculating qualifying payment amounts (QPAs) as arbitration for out-of-network payment disputes between insurers and providers. The rule states payers should calculate QPAs separately for individual and group markets, which is supported by the observed differences in negotiated prices between plans.
"The divergence between HIX and non-HIX commercial group plans that we observe in this study suggests that bifurcating the markets when calculating QPA measures is appropriate," the researchers said.
Lastly, the authors note that in the process of collecting the data for the study, a lack of price transparency led to challenges acquiring comprehensive pricing, as well as difficulties analyzing nonstandardized file formats.
A recent report by PatientsRightsAdvocate.org revealed that only 16% of hospitals are complying with the hospital price transparency rule, nearly 20 months after it went into effect.
"More robust hospital price transparency data, made available as legislated, would enable investigators to evaluate longitudinal trends in contracted rates, compare payment generosity across insurers, and assess the association between prices and market competition," the USC researchers said.
The legislation would protect victims who would otherwise be forced to pay surprise costs out-of-pocket.
A bipartisan bill has been introduced in the House of Representatives which would require private health insurers to fully cover forensic exams for sexual assault victims, protecting them from unexpected bills.
The No Surprises for Survivors Act, backed by Representatives Linda T. Sánchez (D-Calif.), Gwen Moore (D-Wis.), and Carol Miller (R-W.Va.), would ensure victims with private insurance don't have to pay out-of-pocket for rape kits following an attack, beginning in 2025.
Forensic exams are already covered for sexual assault victims under the Violence Against Women Act (VAWA), which was enacted in 1994. However, the law stipulates that the exam must be conducted by an accredited sexual assault nurse examiner (SANE) for it to be free of charge.
A study published in Kaiser Family Foundationfound that 66% of privately-insured women who likely presented for a rape kit after a sexual assault from 2016 to 2018 were charged out-of-pocket costs for some services, with an average out-of-pocket spend of $347.
Building on VAWA, the No Surprises for Survivors Act would require insurers to provide coverage, without cost-sharing, for exams no matter where they are administered, unless it is on the state to reimburse. If a bill is received by the victim and it is the state's responsibility to cover the costs, insurers must inform their members on how to go through the reimbursement process.
Further, the legislation would place forensic exams under the emergency services protections of the No Surprises Act, which protects patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities.
"The last thing a survivor of sexual violence should have to worry about is an unexpected medical bill," Moore said in a statement. "This legislation is needed because too many survivors, grappling with trauma, also become burdened with the cost of a forensic medical exam – even though they shouldn't be. With our bipartisan bill, we build on VAWA's no-cost coverage to ensure victims are protected from cost sharing for exams."
Research shows patients are more willing to utilize emergency services when unexpected bills are not a concern.
The No Surprises Act may have the unintended effect of causing millions more emergency department (ED) visits, according to a study from the Agency for Healthcare Research and Quality.
Since going into effect on January 1, 2022, the federal ban protects patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities.
The study, published in The American Journal of Medical Care, compares ED visits in 15 states with balance billing bans between 2007 and 2018 to ED visits in 16 states without bans to examine the ripple effects of a significant reduction in out-of-pocket payments under the No Surprises Act.
Researchers found that the bans in the 15 states reduced spending per visit by 14%, but also resulted in an increase of 3% in ED visits, which offset the cost savings. The extra visits, however, were considered 9% less urgent than prior to the bans, based on the emergency service index.
From the findings, the authors calculate that the No Surprises Act will lead to 3.5 million more ED visits per year, with the $4.2 billion in extra spending largely wiping away $5.1 billion in savings.
"With such a large reduction in expected out-of-pocket cost of an ED visit, one would expect a possible increase in ED visits after a surprise bill ban, especially with all the media coverage that often surrounds the passage of the ban," the authors state. "Because individuals will no longer have the fear of a possible catastrophic surprise ED bill not covered by their insurer, they may be more inclined to go to the ED in marginal, less severe cases."
The study notes that many of the extra ED visits observed were for the diagnosis categories of "sprains and strains" and "superficial injuries; contusions," showing that the increase in quantity of visits is for less urgent cases.
While the protections afforded by the No Surprises Act is certainly beneficial for patients, it may put pressure on hospitals and health insurers to deal with the increased ED visits and the costs that come from that.
"Because this may also occur more broadly for the 2022 NSA, insurers and primary care physicians may want to renew efforts to prevent costly, avoidable ED visits," the authors conclude.
A study examines the differences in reimbursement for medical decision-making (MDM) billing and time-based billing.
Which billing model leads to more revenue for physicians? That depends on length of patient visit, according to a study published in JAMA Open Network.
The findings revealed time-based billing was associated with higher reimbursement for longer evaluation and management (E/M) visits, whereas MDM billing was associated with higher reimbursement for shorter visits.
To compare the billing models, researchers used 2018 National Ambulatory Medical Care Survey summary data, 2019 billing data for outpatient E/M codes, and 2021 reimbursement rates from CMS.
MDM billing is used under a fee-for-service model, which remains the most common among U.S. physicians and reimburses providers for E/M services based on the number and complexity of problems addressed in a patient visit. This does not include medical record review, documentation, and coordination of care, meaning physicians are left with unreimbursed hours for after-hours work.
Time-based billing, on the other hand, reimburses physicians based on the length of visit, which previously only accounted for time spent face-to-face with patients.
However, changes made to time-based billing guidelines in 2021 now allow physicians to also be reimbursed for time spent on medical record review, documentation, and coordination of care on the day of the visit.
Results of the study showed that yearly E/M revenue was dependent the length of patients visits for MDM billing. The shortest visits, spanning 20 minutes with new patients and 10 minutes with return patients, led to the highest E/M revenue of $846,273.
As visits increased to 30 minutes for new patients/15 minutes for return patients and 40 minutes for new patients/20 minutes for return patients, yearly E/M revenue decreased to $564,188 and $423,137, respectively. The longest visits, spanning 90 minutes for new patients and 45 minutes for return patients, created the least revenue at $188,065.
With time-based billing, revenue remained mostly similar across visit lengths, with $400,432 generated for 30 minutes with new patients/15 minutes for return patients and $458,718 for 40 minutes with new patients/20 minutes with return patients.
The highest revenue was associated with the shortest visit, $567,649 for 20 minutes with new patients/10 minutes with return patients, while the lowest revenue was generated for the longest visit, $385,614 for 50 minutes with new patients/25 minutes with return patients.
Though the findings reveal the advantages of time-based billing for longer visits, the researchers note that MDM billing still leads to the most revenue when visits are shorter, which incentivizes physicians with greater volume.
Where time-based billing really shines is in its capability of freeing physicians up.
"Previous studies have shown that physicians with time constraints are less likely to complete preventive medicine tasks. Therefore, the flexibility in patient scheduling afforded by time-based billing could help physicians better address preventive medicine," the researchers stated.
"A decrease in patients per hour could also be used to help physicians complete non–face-to-face tasks, such as documentation, that traditionally have been pushed to after hours, potentially contributing to decreased physician burnout."
A survey finds the rate of increase for costs across categories such as medical and prescription drugs has slowed but should normalize.
While healthcare costs have seen reduction in the rate of increase, inflation has yet to affect premium rates for employer-sponsored health plans, according to a report by Buck.
The human resources consulting firm released its 43rd National Healthcare Trend Survey of nearly 100 health insurers and health plan administrators, finding that the recent increase in prices is not yet reflected in trend factors payers use to set premiums.
Harvey Sobel, Buck principal, consulting actuary, and survey director, stated that claims shot up in 2021 due to residual demand from COVID-19.
"While a temporary reduction in trends is welcome, activity is projected to normalize in 2022," Sobel said. "Health plans will be under pressure to increase provider reimbursement rates in reaction to the rise in inflation as their provider contracts come up for renewal."
Health insurers and administers surveyed reported medical trend factors that vary by product, averaging 5.8% to 6.9%, down by 1-2 percentage points from the previous survey. The Preferred Provider Organization plan was at 6.4% for the average trend factor, down by 1.4% from the prior year.
With prescription drugs, insurers reported a weighted average trend of 8.1%, down 0.7% from 2021, whereas the weighted average trend reported by Pharmacy Benefit Managers increased from 6.2% to 7.5%.
On the Medicare side, the trend factor for plans continued to increase, up from 5.0% in the previous survey to 5.6%. It marks the sixth consecutive increase since 2018, when the trend factor was a reported 3.0%.
As costs rise for employer-sponsored plans, employers will also feel the brunt.
According to analysis by Aon, employee premiums from paychecks increased by 0.6% in 2022, and costs as a whole are projected to increase to more than $13,800 per employee in 2023.
Inflationary pressures combined with higher utilization rates following COVID will create financial challenges for payers and employers alike.
The Improving Seniors' Timely Access to Care Act, on the strength of overwhelming support, now heads to the Senate.
The widely-supported legislation that aims to reform prior authorization in Medicare Advantage (MA) plans has been unanimously passed in the House, a decision advocated by several medical groups.
Now on its way to the Senate, the Improving Seniors' Timely Access to Care Act is one step closer to establishing an electronic prior authorization program to streamline requests for services under MA plans, which would help mitigate unnecessary denials or delays in care.
MA plans have been under scrutiny of late for their prior authorization processes, with a recent report by the Office of Inspector General finding that MA organizations often delay or deny services for medically necessary care, even when coverage rules are met.
As well as potentially resulting in negative outcomes for patients, unnecessary prior authorization also creates administrative burden for providers.
Several medical groups have already offered recommendations on improving the process and following the House vote to advance the bill, the associations reiterated the importance of prior authorization reform.
Stacey Hughes, executive vice president of the American Hospital Association: "This legislation takes important steps to reduce the burden and complexity of prior authorization requirements imposed by Medicare Advantage plans. These provisions will help Medicare patients access the care they need in a timely manner while reducing the strain on our already taxed health care workforce."
Jack Resneck, president of the American Medical Association: "The House recognized that prior authorization is an insurance companies' practice that is overused, costly, opaque, burdensome to physicians, and harmful to patients due to delays in care. The American Medical Association is committed to fixing prior authorization and made doing so a central plank of our Recovery Plan for America's Physicians."
Anders Gilberg, senior vice president of Government Affairs for the Medical Group Management Association: "The transparency provisions included in this legislation — requiring MA plans to publicly reveal what services are subject to prior authorization, how many are approved, and how long on average they take to approve — will drive plan accountability. By streamlining and standardizing the overly cumbersome and wildly inefficient MA prior authorization process, this legislation will return a focus to the physician-patient relationship and prevent dangerous delays to timely care."
New research finds a correlation between hospitals with fewer beds and lack of adherence to the price transparency mandate.
Hospitals across the board have so far struggled to meet CMS' price transparency requirements, but smaller facilities are more susceptible to noncompliance, according to a study by Northwestern University's Feinberg School of Medicine.
The research, published in ClinicoEconomics and Outcomes Research, identified characteristics of 6,214 hospitals using data from the American Hospital Association Annual Survey, as well as cash prices of commonly performed procedures and visits from Turquoise Health.
While price transparency compliance ranged from 13% to 49% of hospitals studied, the findings revealed that facilities with fewer beds were less likely to be compliant with the rule. Additionally, hospitals located in the South and the West were also associated with less transparency.
Since going into effect on January 1, 2021, the mandate requires hospitals to disclose gross charges online through a comprehensive machine-readable file with all items and services they provide, as well as through a display of shoppable services in a consumer-friendly format.
"The findings of this study shine light on the poor state of price transparency for healthcare services throughout various specialties in hospitals across the US and elucidate pertinent relationships between hospital characteristics and price transparency," the researchers stated.
The study notes that It's unclear if the lower rate of price transparency in smaller hospitals can be attributed to a lack of resources or a reduced penalty for noncompliance on CMS' sliding scale based on hospital bed count.
The rate of price transparency based on region, meanwhile, could be due to less competition in the area, resulting in decreased motivation for hospitals to disclose prices as patients don't have much ability to shop around, the researchers suggest.
However, this reasoning runs counter to the recent JAMA study which found hospitals in less competitive markets and those with greater market shares have higher price transparency compliance rates.
Authors of that study noted that higher compliance rates in less competitive markets were in line with the idea that hospitals safeguard their prices when facing more competition.
It's one thing for hospitals to comply with pricing requirements—it's another for them to do so in a patient-friendly manner.
In the Feinberg School of Medicine study, 62% (3,873) of hospitals reported prices for at least one of the 14 billable healthcare services, which were chosen due to their high volume of usage and representation across medical fields.
Researchers said it was a "tedious task" to obtain list prices from hospital chargemasters, which involves navigating multiple hospital websites, finding the correct chargemaster listed, and understanding billing terminology.
So even if a hospital is being transparent with its pricing, the complexity of the process to find the prices means patients may not end up benefitting anyways.
"Thus, the current CMS legislation’s efforts at price transparency fall short of its aim to provide patients with the necessary information to make informed care decisions," the researchers stated.
The groups allege the health insurer underpaid claims submitted by patients for services covered through MultiPlan.
The American Medical Association (AMA), as well as the Medical Society of New Jersey and the Washington State Medical Association, have joined a class action lawsuit against Cigna alleging underpayments for claims through the MultiPlan network, the nations' largest third-party network.
Originally filed in June by Cigna members, the lawsuit takes issue with the health insurer's reimbursements at its non-participating providers rate instead of a rate for a MultiPlan contract when services were received from a participating provider. As such, Cigna members were "exposed to the threat of balance billing," the lawsuit states.
The plaintiffs argue that MultiPlan contracts prohibit providers from billing patients for the difference between the original charges and the discounted rates, which Cigna is responsible for.
They claim the payer "also breached its fiduciary duties, including its duty to honor written plan terms and its duty of loyalty, because its conduct serves Cigna's own economic self-interest and elevates Cigna's interests above the interests of plan member patients."
AMA president Jack Resneck Jr. criticized Cigna for prioritizing its "economic self-interest" above its commitment to physicians and patients in the MultiPlan Network.
"The AMA and other physician organizations allege that Cigna's misconduct is riddled with conflicts of interest and manipulations that routinely shortchanged payments to MultiPlan Network physicians and interfered with the patient-physician relationship by ignoring the MultiPlan contracts and making incorrect statements to patients about their liability for the unpaid portion of the billed charges," Resneck said in a statement.
"By joining Stewart v. Cigna as a plaintiff, the AMA hopes to shed light on Cigna's misconduct and create remedies so that patients and physicians can look forward to getting what they are promised."
The physician group responds to the ruling by a Texas judge deeming a piece of the Affordable Care Act (ACA) unconstitutional.
The American Medical Association (AMA) has pushed back on the controversial ruling against a provision of the ACA, strongly stating that preventive care requirements must be upheld.
AMA president Jack Resneck called the elimination of no-cost preventive care "unwise and unthinkable" in a statementfollowing Judge Reed O'Connor's decision to strike down the ACA law mandating employers to cover an HIV prevention drug.
The federal judge ruled in favor of Steven Hotze, owner of Braidwood Management, who argued that being forced to buy health insurance for his employee to cover preexposure prophylaxis (PrEP) violates his religious beliefs.
Resneck stated: "Providing insurance coverage for drugs that prevent the transmission of infectious disease does not violate anyone’s religious freedom—to the contrary. This type of preventive care saves lives."
Preventive care not only saves lives and saves money, it's part of physician' ethical obligation to take care of patients, Resneck argues. He also pointed to research by HHS that found more than 150 million people benefited from preventive care services in 2020 alone.
"The AMA is alarmed by this line of judicial reasoning and we fear it could turn back the clock and limit access—not only to PrEP, but also to a long list of preventive services that physicians and patients depend on," Resneck said.
As the legal process for the preventive provision plays out, Resneck believes empowering, educating, and encouraging patients about their health is necessary.
He said: "In short, we need to build on the gains we've made under ACA, not abandon vital components of the law just as we’re starting to reap their benefits."
