Cold Iron Truth

Surprise medical billing may eliminate restrictive networks


Certainly, this has been a tumultuous year for health care, as well as the nation in general. There is so much to cover it is hard to know where to begin.

PAST DUE stamped on a past due Medical invoice. KLH49/iStock/Getty Images

Against a background of a swelling pandemic, I remain confused about the new evaluation and management coding system, and suspect there will be much more training to be rolled out. It is excellent news that the Paycheck Protection Program has been renewed for a second pass, if you can demonstrate that you suffered at least a 25% drop in income for at least one quarter last year, and have fewer than 300 employees – which covers most dermatology practices. I plan to discuss the impact of price transparency in a future column, but today will discuss one area, where we have had the passage of major health care legislation, that may have been overlooked.

The surprise medical billing act, or “No Surprises Act,” was a bipartisan congressional agreement, which means it is likely to “stick” no matter the change in executive or legislative branches.

Starting in January 2022, patients are protected from surprise medical bills. For nonemergency services and services outside hospitals and other facilities, a patient can only be billed for the coinsurance/copay that they would have had if the patient had been in network unless you go through a consent process by which you inform the patient that you are out-of-network, inform them of the costs, and inform them of other in-network providers. It also requires that patients’ in-network cost-sharing payments for out-of-network surprise bills are attributed to a patient’s in-network deductible.

In section 103, it further states that, where out-of-network rates are determined, there will be a 30-day open negotiation period for providers and payers to settle out-of-network claims. It also states that if the parties are unable to reach a negotiated agreement, they may access a binding arbitration process – referred to as an independent dispute resolution (IDR) – in which one offer prevails. Providers may batch similar services in one proceeding when claims are from the same payer. The IDR process will be administered by independent, unbiased entities with no affiliation to providers or payers.

The IDR entity is required to consider the market-based median in-network rate, alongside relevant information brought by either party, information requested by the reviewer, as well as factors such as the provider’s training and experience patient acuity, and the complexity of furnishing the item or service, in the case of a provider that is a facility. Other factors include the teaching status, case mix and scope of services of such facility, demonstrations of good faith efforts (or lack of good faith efforts) to enter into a network agreement, prior contracted rates during the previous 4 plan-years, and other items. Billed charges and public payer (Medicare and Medicaid) rates are excluded from consideration. This should result in a payment closer to private insurance rates.

As many of you know, another one of the long-term outrages by insurers has been the closure of their networks and delisting of dermatologists. I have written about this situation before in this column. Insurers have also refused to update their provider lists, effectively denying care by the magical process of not having to pay for medical care, because there aren’t any medical providers.


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