|VIDEO: Insurance Companies Have Weaponized the No Surprises Act, May Impact Patient Care
By Dave Fornell | December 7, 2022
Ed Gaines, JD, CCP, vice president of regulatory affairs and industry liaison, Zotec Partners, discusses the No Surprises Act on radiology at the Radiological Society of North America (RSNA) 2022 meeting. Gaines works with RSNA on billing and Medicare issues and spoke in sessions at the RSNA 2022 meeting.
The No Surprises Act (NSA) was created to protect patients from high cost, surprise medical bills and remove consumers from payment disputes between a provider or healthcare facility and their health insurance plan. But while the act seems like a straightforward policy to most people not involved in healthcare, costs in the U.S. healthcare system can vary greatly depending on the level of a patient’s insurance, deductibles, deals negotiated between insurance companies and specific providers, or if a patient is being covered by Medicare, Medicaid or paying cash. Prices in the healthcare supply chain also vary depending on the hospital and deals negotiated with vendors for everything a hospital or clinic uses, from disposables and drugs, to durable equipment and medical devices.
The NSA has been leveraged by some insurance companies as a way to keep their own costs low by forcing providers to adjudicate unpaid bills or underpaid bills using a cumbersome independent dispute resolutions process.
“Insurance companies have weaponized the No Surprised Act and I don’t think the average person on the street knows. They think they have coverage for radiology services, for emergency services or for anesthesia, but I don’t think they have any idea that their insurance plans have taken this law and used it as a battering ram to provider groups they have been in contract with for years to say, hey, under this new law we don’t have to pay that much anymore. Sorry, if you don’t like it, you can file with the process where there are 80,000 claims log-jammed at the federal level. And that is really what is happening right now.”
While he said insurance companies are losing these challenges about 80% of the time, it is adding a lot of extra work, cost, time and frustration to providers who just want to be paid for the medical services they provide.
“I think the physicians reach a point of frustration between burnout and suicide with all of the factors hitting them, and I am concerned about who is going to care for us,” Haines explained. “I hear this level of frustration, and I have been practicing healthcare law for 30 years and I have never heard it this high. So part of my message to the patients is that they are going to have to advocate for the physicians, the hospitals and that service they expect is going to be there.”
He explained that the current burnout rate among physicians over constant issues with getting paid amid rising costs and lower reimbursements is causing an issue with the American healthcare system. He said there also is a shortage of physicians that is growing and it will eventually lead to people not being able to get the care they need.
At the same time, he said health insurance costs are rising fast and insurance companies are reporting record profits.
“There is plenty of money in the system, it is maybe just being misdirected,” Gaines said. “We spend more per capita than any other country on the planet and yet we don’t have the outcomes.”
Gaines said he tells providers there are still issues with the NSA that need to be worked out, including legal challenges. He details the first major court case challenging the NSA from Texas in the interview. Since then, two more cases have been filed to challenge the rules of the NSA.
The first Texas legal challenge resulted in the judge sending the rule for how the policy is carried out back to the federal agencies for further refinement and clarification. That case will be back in court for review in February 2023.
To read more, go to Radiology Business.
6 Things to Know About the 1st Year of the No Surprises Act
By Rylee Wilson | December 6, 2022
The No Surprises Act, which protects consumers from out-of-network charges for emergency care and other services, took effect Jan. 1 of this year.
While data shows the new policy is saving patients money, questions and lawsuits over how disputes about bills will be resolved between payers and providers abound.
Here are six developments Becker’s has reported in the act’s first year in effect.
Payers say the act has saved consumers money A report from AHIP and the Blue Cross Blue Shield Association found the bill has saved 9 million patients from surprise medical bills since January. A separate study found the act could result in 3 million more emergency room visits each year, because individuals no longer fear catastrophic bills.
CMSissued a final rule on how disputes between payers and providers over out-of-network rates will be solved in August In November, the House Ways and Means Committee called the rule “seriously disappointing.” Critics have argued the rule gives too much power to payers.
Disputes have centered on the arbitration processThe Texas Medical Association filed its third lawsuit challenging the act on November 30. In a news release, the association said it was challenging rules that “skew negotiations in favor of health insurers so strongly that health insurers will force physicians out of insurance networks and physicians will face significant practice viability challenges, struggling to keep their doors open in the wake of the pandemic.”
The Texas Medical Association filed its first No Surprises Act lawsuit in October 2021, successfully arguing that requiring arbitrators to heavily weigh figures created by insurers conflicted with the law and provided insurers with an unfair advantage unintended by Congress.
The group filed a second lawsuit in September, arguing the final rule “unfairly advantage[s] health insurers by requiring arbitrators to give outsized weight or consideration to the [qualifying payment amount].” A hearing in that case is scheduled for Dec. 20.
Many provider organizations have backed the Texas Medical Association’s challengesIn October, the American Hospital Association and the American Medical Association, along with 30 additional national and state medical groups, filed amicus briefs supporting the Texas Medical Association’s second lawsuit.
Payers have backed HHS’ ruleAHIP filed an amicus brief Nov. 16 in Texas Medical Association v. HHS. The association says the arbitration rule does not give payers the upper hand. In a press release, the trade association said there is “no basis” to providers’ claims that the arbitration rates will cause payers to lower reimbursement rates and narrow networks.
There is a lengthy backlog of claimsHHS has received more than 90,000 claims since launching the independent dispute resolution portal in April.
To read more, go to Becker’s Payer Issues.
CMS Proposes Streamlining, Automating Prior Authorizations
By Nona Tepper | December 6, 2022
The Centers for Medicare and Medicaid Services aims to overhaul health insurance prior authorizations under a propose rule published Tuesday.
The regulation would require Medicare Advantage, Medicaid and health insurance exchange carriers to ease their prior authorization processes and respond to “urgent” requests within 72 hours and standard requests within seven days. This would halve the amount of time Medicare Advantage plans currently have to respond to clinicians’ prior authorization requests, according to CMS.
Insurers would have to justify denials and publicly report data on their prior authorization decisions. Insurers and providers could also be required to implement technology that would allow patient health information to flow from one payer to another so that medical records would be available when policyholders change insurance companies.
“The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote healthcare data sharing to improve the care experience across providers, patients and caregivers—helping us to address avoidable delays in patient care and achieve better health outcomes for all,” CMS Administrator Chiquita Brooks-LaSure said in a news release.
CMS estimates the proposed rule would save providers more than $15 billion over 10 years.
“The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans,” Ashley Thompson, the American Hospital Association’s senior vice president for public policy analysis and development, said in a news release. “Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens healthcare providers and adds unnecessary costs to the healthcare system.”
For additional information on the proposed rule, please see below:
Fact sheetPress release
To read more, go to Modern Healthcare.
HHS Gives Providers More Time for Good Faith Estimate Compliance
By Jacqueline LaPointe | December 6, 2022
HHS has extended enforcement discretion for the delivery of some good faith estimates (GFEs) under the No Surprises Act, according to new guidance.
The guidance released by HHS on Friday says that CMS will not begin enforcing the No Surprises Act requirement that healthcare providers deliver GFEs to uninsured and self-pay individuals when there are co-providers or co-facilities. Enforcement of the No Surprises Act requirement was slated to start on Jan. 1, 2023. Instead, HHS is holding off on enforcement until future rulemaking.
GFEs are price estimates for any item or service that is reasonably expected to occur during a scheduled procedure or requested item or service. The estimates include any items or services that may involve providers or facilities outside of the one scheduling the service. These co-providers and co-facilities, as they are named in the regulations, must submit GFE information within one business day of a convening provider’s request.
However, industry groups have expressed concerns about getting GFEs, including co-provider and/or co-facility price estimates, to patients within the statutory timeframe, which is three days after an individual requests the price estimate or after the service is scheduled. The groups have cited administrative burden and data exchange limitations as reasons why HHS should modify or revisit GFE requirements.
“By extending this exercise of enforcement discretion, HHS aims to promote further interoperability across the [healthcare] industry and encourage providers, facilities, and other industry members to focus resources towards adopting interoperable processes for exchanging information,” the guidance states.
HHS believes that healthcare providers and facilities will need to widely adopt “a standards-based application programming interface (API)” in order to “achieve industry-wide interoperability for the transmission of GFE data between convening providers and facilities and co-providers and co-facilities.” The Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standard could support the interoperability providers need to deliver full GFEs to individuals, the federal department adds.
“The industry continues to make progress in developing data interchange standards to support the requirements of the No Surprises Act,” Charles Stellar, president and CEO of the Workgroup for Electronic Data Interchange (WEDI), said in a statement.
To read more, go to Revcycle Intelligence.
18 Million Could Lose Medicaid Coverage At End of PHE, New Estimates Show
By Andrew Cass | December 6, 2022
Updated estimates from the Urban Institute and Robert Wood Johnson Foundation show that 18 million people could lose Medicaid coverage when the COVID-19 public health emergency ends.
Six things to know:
The estimates in the Dec. 5 report are up 2 million from a March 9 analysis, which projected 16 million could lose coverage at the end of the public health emergency. The new report states that while many who are currently enrolled in Medicaid will transition to other coverage options, 3.8 million will become uninsured. Nineteen states will see their uninsured rates spike by more than 20 percent Of the 3.8 million who will become uninsured, about 1.5 million will be eligible for Marketplace premium tax credits, but will not enroll. An estimated 3.2 million children will transition from Medicaid to separate Children’s Health Insurance Program plans.State policy determination during the transition following the public health emergency declaration will have a “crucial impact on how many people lose coverage, how rapidly they lose it, and how many people enroll in other coverage,” Matthew Buettgens, senior fellow at the Urban Institute, said in a news release shared with Becker’s. To read more, got to Becker’s Payer Issues.
What do Google and Amazon Really Want from Medical Imaging?
By Dave Pearson | December 5, 2022
Big Tech’s recent expansions into medical imaging have business watchers scrambling to decipher the unspoken stratagems beneath the conspicuous moves.
Particularly eyebrow-raising among these have been Google’s assignment of an evident new medical-imaging division, Medical Imaging Suite, and Amazon’s HealthLake-based coordination of partner companies that have considerable imaging expertise as well as established market presence.
At the Acceleration Economy Network, a brief item suggests the two giants are “battling for dominance” in medical imaging.
“While Google Cloud is focusing on pain points and reducing person hours, Amazon Web Services appears to be taking a more comprehensive approach,” Spain-based business analyst Kieron Allen writes. “It’s looking at the introduction of cloud-based medical image retrieval and analysis as a driver for cloud adoption.”
Allen sees the corporations’ expansions in medical imaging as a logical extension of their recognition that imaging is, in various ways, “advancing at a staggering rate.”
The field’s growth makes its mass relocation to the cloud inevitable if not yet imminent, he implies.
He adds that AWS is, for its part, “ultimately providing a scalable solution that should encourage healthcare providers to switch [medical imaging workflows] to the cloud.”
To read more, go to Radiology Business.
Texas Medical Association Files Another Lawsuit Against No Surprises Act
By Susan Morse | December 1, 2022
The Texas Medical Association has filed its third lawsuit against the No Surprises Act.
The complaint was made Wednesday by the TMA and Tyler Regional Hospital in Texas in the U.S. District Court for the Eastern District of Texas. It is against the Department of Health and Human Services, which released the rule; the Department of Labor; and the Department of the Treasury.
The lawsuit challenges certain portions of implementation of the July 2021 interim final rule. Specifically, the TMA and Tyler Regional Hospital allege that the rules “artificially deflate” the Qualifying Payment Amount, an insurer-calculated amount used in arbitration when deciding the appropriate out-of-network rate presented by physicians and insurers.
The system is rigged against doctors and in favor of the insurer, the TMA said by statement. The TMA and health system want a declaration that the federal departments acted unlawfully and vacate provisions of the July rule.
WHY THIS MATTERS
While the Qualifying Payment Amount is supposed to be the median in-network rate, the methodology conflicts with the way that the No Surprises Act requires insurers to calculate the payment amount, the TMA said. Physicians have the scales tipped against them from the outset of negotiations, TMA president Dr. Gary W. Floyd said. There is also a lack of transparency, he said.
“TMA is concerned that these provisions unfairly disadvantage physicians in payment disputes with health insurers and will ultimately rob patients access to physicians’ care,” Floyd said.
The rule allows insurers to include “ghost rates” in their QPA calculations. These are contract rates with physicians and providers who don’t actually provide the health service in question, the TMA said. Because there is little motivation for those not providing the service to negotiate rates, this lowers the rates for the providers who actually provide the services.
The TMA contends that the rule allows insurers to use the rates of physicians who are not in the same or a similar specialty. It also says that the rule requires insurers to use an amount other than the total payment in calculating QPA when a contract includes risk sharing, bonus or penalty or other incentive-based adjustments.
Also, self-insured plans are able to opt in to a lower QPA, the TMA said.
To read more, go to Healthcare Finance.