Amid Lawsuits, Radiologist Opposition, Biden Administration Touts Start of Surprise Medical Bill Ban
By Marty Stempniak | January 4, 2022
Amid multiple lawsuits and opposition from radiologists and other physicians, the Biden administration touted the start of its new ban of surprise medical bills on Monday.
The No Surprises Act went into effect Jan. 1, shielding privately insured consumers from receiving unexpected IOUs for out-of-network care in most instances. In addition, the law will require that providers give uninsured and self-pay patients overviews of their expected costs, among other key information, Health and Human Services said in an announcement.
HHS Secretary Xavier Becerra believes these changes mark the “most critical consumer protection law” since the Affordable Care Act of 2010.
“After years of bipartisan effort, we are finally providing hardworking Americans with the federal guardrails needed to shield them from surprise medical bills,” he said in a Jan. 3 statement. “We are taking patients out of the middle of the food fight between insurers and providers and ensuring they aren’t met with eye-popping, bankruptcy-inducing medical bills.”
Becerra pointed to a recent HHS report, which found that nearly 1 in 5 privately insured patients receive a surprise bill after elective surgery, visiting an ED or giving birth. On average, the cost could range from $750 to upward of $2,600, according to the HHS Office of the Assistant Secretary for Planning and Evaluation.
Along with banning unanticipated bills, the No Surprises Act requires that cost sharing for emergency services is based on the in-network rate, regardless of prior authorization. It would also forbid bills from certain out-of-network providers when patients visit an in-network hospital for a procedure. And facilities must now share easy-to-understand notices, detailing such new protections and who patients can contact if they believe providers are violating the new law, HHS said.
“For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill,” the administration said in a corresponding fact sheet.
The announcement comes after several provider groups including the American College of Radiology filed suit to stop one key provision in the No Surprises Act. ACR and others have said they support efforts to protect patients from financial harm. However, they’re concerned the newly established process to settle payer-provider reimbursement disputes is skewed in favor of commercial insurers.
To read more, go to Radiology Business.
Are Women at Higher Breast Cancer Risk Getting Supplemental MRI?
By Kate Madden Yee | January 3, 2022
Women at higher risk for breast cancer who are recommended for supplemental MRI screening may not be getting it, according to a research poster presented at the recent RSNA 2021 meeting.
The lack of follow through with supplemental breast MRI seems particularly high among racial and ethnic minorities and those in lower income brackets, Dr. Dayna Levin of the University of Pennsylvania in Philadelphia said in her presentation.
“In high-risk patients, combined mammography and MRI screening leads to higher cancer detection and better overall survival,” she said. “[Our findings] highlight the need to increase rates of supplemental breast MRI screening to address underlying racial and economic disparities that exist in our high-risk population.”
Finding breast cancer early improves outcomes for women, and breast MRI finds more cancer in high-risk women than mammography or ultrasound, Levin and colleagues noted; the American College of Radiology (ACR) recommends that women at higher risk for the disease undergo annual breast MRI. But it’s unclear whether this population is actually getting this additional care.
“National compliance levels [with supplemental breast MRI are] not well known, however, small studies suggest wide underutilization,” Levin said. “MRI screening rates represent a healthcare disparity and are significantly lower in minority and low-income populations.”
Levin and colleagues conducted a study that included data taken from electronic health records at three breast imaging centers that identified 2,431 women with elevated Gail risk scores (more than 20%) who presented for either screening or diagnostic mammography and underwent a breast MRI within the following two-year period. The team analyzed the patient data for socioeconomic and demographic factors such as income, race, and age.
The group found that less than 20% of these high-risk patients received supplemental breast MRI screening. It also found the following:
• Asian women were 88% less likely to get a supplemental breast MRI than white
• Black women were 70% less likely to get a supplemental breast MRI than white
• Women with median incomes of more than $150,000 were 27% more likely to
undergo screening breast MRI, while those with median incomes of less than $50,000
were 54% less likely.
• Women over 50 were 36% less likely to get supplemental screening breast MRI than
those under 50.
What are the barriers to breast MRI screening? Time constraints with primary care providers and lack of familiarity with risk-assessment tools; patients’ lack of insurance, or out-of-pocket costs; and anxiety about undergoing MRI, Levin noted.
To read more, go to Aunt Minnie.
CMS Releases Guidance on Healthcare Worker Vaccination Mandate
By Kelly Gooch | January 3, 2022
CMS has released guidance and survey procedures for the 25 states where its COVID-19 vaccination mandate for healthcare workers is not currently blocked.
The guidance, released Dec. 28 to state survey agency directors, outlines enforcement action thresholds that CMS said will help surveyors in assessing compliance.
The guidance does not apply to 25 states where the mandate is blocked: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, West Virginia and Wyoming.
A CMS spokesperson told Becker’s facilities in these states are not required to comply with the rule, pending future developments in litigation. However, the rule does currently apply to facilities participating in the Medicare and Medicaid programs in the remaining 25 states, Washington, D.C., and the territories.
According to the guidance, facilities are compliant if, by Jan. 27, they have established policies and procedures for ensuring that eligible staff are vaccinated, and all staff have received at least one dose, have a pending request for an exemption, have been granted a qualifying exemption, or have been identified as having a temporary delay as recommended by the CDC.
By Feb. 28, eligible staff must have completed the vaccination series (one dose of Johnson & Johnson or two doses of Pfizer or Moderna), have been granted an exemption or have been identified as having a temporary delay as recommended by the CDC.
CMS said federal, state, accreditation organization and CMS-contracted surveyors will begin surveying for compliance 30 days after publication of the guidance.
Facilities that fail to maintain full compliance within 90 days after publication of the guidance may be subject to enforcement action, with termination of participation from the Medicare and Medicaid programs as a final and last resort. CMS said the agency seeks to bring healthcare facilities into compliance, and “termination would generally occur only after providing a facility with an opportunity to make corrections and come into compliance.”
CMS released the guidance as the U.S. Supreme Court has scheduled a special hearing Jan. 7 to consider cases involving the mandate for healthcare workers and the Occupational Safety and Health Administration’s vaccinate-or-test requirement for large businesses.
The nation’s highest court will make a final ruling on the mandate for eligible staff at healthcare facilities. President Joe Biden’s administration has asked that the court allow the mandate to take effect across the country.
More information about the guidance is available here.
To read more, go to Becker’s Hospital Review.
American College of Radiology Sues Federal Government to Halt Controversial Piece of Surprise Billing Rule
By Marty Stempniak | January 3, 2022
The American College of Radiology is suing the federal government to stop one key aspect of legislation meant to protect patients from surprise medical bills for out-of-network healthcare services.
ACR filed the complaint on Dec. 22 in a Chicago federal district court, joined by the American College of Emergency Physicians and American Society of Anesthesiologists. They’re hoping to halt a controversial provision in the “No Surprises Act” used to resolve payment disputes between commercial insurers and providers.
Under Congress’ original intent, independent third parties were supposed to consider a host of factors before reaching a final reimbursement amount. But physicians believe the Biden administration’s interpretation of the final rule misunderstands lawmakers’ original guidance and tips the scales in favor of insurers.
“The conscious decision by the White House to ignore the specific legislative language and intent of the ‘No Surprises Act’ as the new law is implemented has empowered insurers to drastically cut reimbursement, narrow medical networks and restrict patient access to their chosen providers — including radiologists,” ACR said in a Dec. 22 news update. “To draw attention away from this devastating impact, the government is attempting to financially pit providers against patients, which can only further harm the healthcare system and the doctor-patient relationship.”
ACR et al. joins several other provider groups already suing the feds over the rule, including American medical and hospital associations, Renown Health System in Nevada, UMass Memorial Health in Massachusetts and the Texas Medical Association. The college and others believe the rule is now emboldening payers to pad their profits using “strong arm” tactics. As an example, ACR and others have cited letters sent by the Blue Cross Blue Shield of North Carolina in November, threatening to cut off payments to docs who do not accept sizable reimbursement cuts.
Radiologists and other docs emphasized the suit would not impact provisions to protect patients, nor increase their out-of-pocket costs. However, they want independent arbitrators to consider a host of factors when settling disputes, such as quality of outcomes, market share, patient acuity and prior contract history between the two parties. As implemented, the law would make the “qualifying payment amount,” a number arbitrarily set by insurers, as the primary factor in such determinations.
“We are left with a law that will tilt market forces in favor of insurers and they are already exploiting their newfound incentive to push emergency physicians out of network. Legal remedy is necessary so that the [interim final rule] does not undermine the entire dispute resolution process,” Gillian Schmitz, MD, president of the American College of Emergency Physicians, said in a statement.
On the other side, HHS Secretary Xavier Becerra has defended the administration’s implementation of the law, urging physicians to “tighten their belt.” Groups
representing patient and insurer interests have also voiced their support.
More information about the lawsuit is available on the ACR website.
To read more, go to Radiology Business.