Op-ed: Congress Needs to Address Looming Physician Reimbursement Cuts
By Rep. Larry Bucshon M.D. | October 19, 2021
For over 19 months, our nation’s doctors, nurses and other healthcare workers have been on the front lines of the COVID-19 pandemic fighting each day for the health and well-being of our loved ones. With the insurgence of the delta variant flooding hospitals across the nation with patients, our nation’s healthcare workers have been once again dealing with overcrowded hospitals, staffing shortages and equipment issues.
Now with more than 700,000 deaths in the U.S. due to the pandemic and the surges in COVID-19 cases during the past several months, it is no secret that our healthcare professionals are spread thin. This makes the decision by the Biden Administration and Democrats in Congress to not address looming physician pay cuts during a pandemic completely incomprehensible.
Due to a budget-neutrality requirement in federal law, the effect of increasing the Medicare reimbursement rate for primary-care physicians is that the Centers for Medicare and Medicaid Services must decrease the reimbursement rate for other providers. As a result, many specialists, therapists and other physicians are now facing a substantial reimbursement cut next year—up to 9% for many providers. While I am strongly supportive of increasing reimbursement for primary-care physicians, increasing the rate for primary-care physicians at the expense of other providers and surgeons is misguided and dangerous for patients.
The ramifications of allowing such a reimbursement cut to go into effect would only further strain our healthcare system that is already under unprecedented stress from the pandemic, threatening patient access to medically necessary services.
Physicians are among the everyday heroes keeping our families healthy, our communities out of harm’s way, and our livelihoods protected during this pandemic. Now is not the time to ask them to take a reimbursement cut.
To read more, go to Modern Healthcare.
HHS Proposes Withdrawing Trump ‘Good Guidance’ Rules
By Jessie Hellman | October 19, 2021
The Biden administration on Tuesday announced plans to withdraw Trump-era rules that make it harder for regulators to punish individuals and organizations for not following Health and Human Services Department guidance.
The rules, issued in the final months of the Trump administration, ban HHS from penalizing individuals and organizations for noncompliance with agency guidance and requires the agency only carry out civil enforcement actions using standards that are publicly stated.
HHS proposed withdrawing the rules Tuesday, arguing it creates “unnecessary hurdles” to issuing guidance and bringing enforcement actions and is inconsistent with the goals of the Biden administration.
To read more, go to Modern Healthcare.
ASA-Endorsed Congressional Letter Urges House Leadership to Prevent Medicare Payment Cuts
October 15, 2021
This week, a bipartisan group of over 245 members in the House of Representatives led by Rep. Ami Bera (D-CA-7) and Rep. Larry Bucshon (R-IN-8) urged Speaker of the House, Nancy Pelosi (D-CA-12), and House Minority Leader, Kevin McCarthy (R-CA-23), to take immediate action to avoid the Medicare payment cuts scheduled to take effect at the start of 2022. ASA previously announced its support for the letter, which states that the planned 9 percent cuts on payments for anesthesiologists and other specialties will “strain our health care system and jeopardize patient access to medically necessary services.” ASA-member grassroots activists generated over 1,300 messages to the Hill and played a key role in securing many of the Congressional signatories.
ASA teamed with a coalition of over 140 medical organizations at the national, state, and local levels in backing the Bera-Bucshon letter’s efforts to push for immediate Congressional action that will prevent the impending payment cuts and preserve financial stability for medical practices across the country. The letter also calls on Congress to quickly begin work on long-term reforms for a fairer Medicare payment system.
ASA continues to strongly oppose any Medicare payment cuts.
To read more, go to ASA’s website.
Surprise-billing Rule ‘Puts a Thumb on the Scale’ to Keep Arbitrated Costs in Check
By Julie Appleby | October 14, 2021
Patients are months away from not having to worry about most surprise medical bills — those extra costs that can amount to hundreds or thousands of dollars when people are unknowingly treated by an out-of-network doctor or hospital.
What’s not clear is whether the changes in law made by the No Surprises Act — which takes effect Jan. 1 — will have the unintended consequences of shifting costs and leading to higher insurance premiums.
Probably not, many policy experts told KHN. Some predict it may slightly slow premium growth.
The reason, said Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, is that a rule released Sept. 30 by the Biden administration appears to “put a thumb on the scale” to discourage settlements at amounts higher than most insurers generally pay for in-network care.
That rule drew immediate opposition from hospital and physician groups, with the American Medical Association calling it “an undeserved gift to the insurance industry,” while the American College of Radiology said it “does not reflect real-world payment rates” and warned that relying on it so heavily “will cause large imaging cuts and reduce patient access to care.”
Such tough talk echoes comments made while Congress was hammering out the law.
The most recent guidance is the third issued to implement the law, which passed in late 2020 after a years-long battle. It was signed by then-President Donald Trump.
The No Surprises Act takes aim at a common practice: large, unexpected “balance bills” being sent to insured patients for services such as emergency treatment at out-of-network hospitals or via air ambulance companies. Some patients get bills even after using in-network facilities because they receive care from a doctor who has not signed on with an insurer’s network.
Patients were caught in the middle and liable for the difference between what their insurer paid toward the bill and the often-exorbitant charges they received from the provider.
Once the law takes effect next year, patients will pay only what they would have if their care had been performed in network, leaving any balance to be settled between insurers and the out-of-network medical providers. The law also gives insurers and providers 30 days to sort out discrepancies.
Anesthesiologists Accuse UnitedHealth of Anticompetitive Network Exclusions
By Nona Tepper | October 11, 2021
The American Society of Anesthesiologists is calling on the Justice Department to investigate the “high rate” of provider contracts the nation’s largest insurer is canceling early, a practice the lobbying group says leads to higher costs for patients and employers and threatens providers’ financial viability.
UnitedHealth Group’s UnitedHealthcare arm has been removing a growing number of anesthesiologists from its provider networks, the organization wrote in a letter sent to acting Assistant Attorney General Richard Powers on Thursday.
The specialty society, which represents 54,600 anesthesiology providers, has heard from “hundreds and hundreds” of practices of all sizes and type who complain that the insurer is canceling contracts at least six months ahead of time, leaving anesthesiologists out of network and paid a fraction of the rates they once received, American Society of Anesthesiologists President Dr. Beverly Philip said.
“It’s been crescendoing. It’s becoming more common,” Philip said.
UnitedHealth Group negotiates thousands of contracts each year and reaches competitive agreements with the vast majority of them, a spokesperson wrote in an email.
“Unfortunately, a small number of groups, many of which are private equity-backed, are working to protect their ability to continue charging egregiously high rates,” the spokesperson wrote. “The real reason many of them no longer participate in our network is because they expect to be paid double or even triple the median rate we pay other physicians providing the same services. While these egregiously high rates help meet profit expectations, they also drive up the cost of care and make healthcare less affordable for people across the country.”
Patients experience a high number of surprise bills for anesthesiology, partly because they typically do not get to choose the anesthesiologists, research shows. In 2015, 12% of in network hospitals bills included surprise charges for anesthesiology services, according to a Yale University study published by Health Affairs in 2019. These providers charged more than eight times the Medicare rates for their services, the study found.
Over the past few years, the American Society of Anesthesiologists has fielded similar complaints about insurers kicking its members out of their networks, including Anthem’s Cigna, CVS Health’s Aetna and some Blue Cross and Blue Shield carriers, Philip said. UnitedHealthcare is by far the most common insurer American Society of Anesthesiologist members cite, she said.
To read more, go to Modern Healthcare.
AHA asks Congress to Stop Looming Medicare Cuts
By Jessie Hellmann | October 6, 2021
The American Hospital Association is urging Congress to stop cuts to Medicare before they take effect next year, citing the uncertain trajectory of the COVID-19 pandemic and possible variants.
“Now is not the time for reductions in Medicare payments to providers,” Stacey Hughes, executive vice president of AHA wrote in a letter to Congressional leadership.
Without Congressional action, Medicare will face a 4% cut triggered by the COVID-19 relief bill that passed earlier this year.
Because the law raised the deficit, Medicare and other programs will be subject to spending cuts under the Pay-As-You-Go Act passed by Congress in 2010.
Congress is likely to waive PAYGO, avoiding the cuts, but will likely only do so at the last moment, putting providers on edge.
Major Insurers Running Billions of Dollars Behind on Payments to Hospitals and Doctors
By Jay Hancock | October 6, 2021
Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.
Anthem, like other big insurers, is using the covid-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of ‘Everyone’s distracted. We can get this through,’” she said.
Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.
Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they’ll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with Covid surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government.
“We recognize there have been some challenges” to prompt payments caused by claims processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.
For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight Covid.
Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.
To read more, go to Kaiser Health News.
ASA Fighting Flawed New Surprise Medical Bill Regulations
October 4, 2021
Last week, the Biden Administration released its newest set of regulations to implement the federal “No Surprises Act.” While earlier rules addressed other sections of the law, this set of rules focuses on the independent dispute resolution (IDR) process – the mechanism that Congress created to adjudicate payment disputes between health insurance companies and physicians.
During last year’s Congressional debate about surprise medical bills, ASA co-led a medical specialty coalition focused on ensuring that physicians were empowered to secure fair payment rates from insurers for out-of-network payment disputes through the IDR process. ASA worked closely with Congressional allies on the final language included in the No
Surprises Act, that captured Congress’ intent to create an IDR process that was appropriately balanced and did not favor either the insurer or the physician in claims disputes. ASA supported the final language, which required the arbiter to consider a full range of factors, including patient acuity or complexity of services, demonstrations of previous good faith
efforts to negotiate in-network rates and previously contracted rates, in addition to the insurers’ median in-network rate.
With the release of the rule last week, we learned that the responsible federal departments ignored Congressional intent and statutory language and, instead, designed an IDR process that heavily favors health insurance companies in payment disputes. The language in the rule directs the arbiter to give priority to the insurer-calculated median in-network amount, called the qualifying payment amount (QPA), over the other considerations ASA worked to include in the law. The result is effectively rate-setting, which is entirely unacceptable to ASA.
On Friday, ASA issued a joint statement with other medical specialty organizations to denounce this plan. We have also begun to work jointly with other medical specialty organizations and hospital stakeholders to repair the QPA flaw. As first step, we need Congress to reengage to affirm their Congressional intent.
Please contact your members of Congress to ask that they fix this flawed rule.