ARTICLE
Congress will likely pass legislation on surprise billing by year's end, Sen. Bill Cassidy, MD (R-La.), predicted. "If this issue concerns you, you need to be speaking to your congressman, congresswoman, or your senator," Cassidy said. "I'm telling you, this will be decided soon." Congress is debating two types of solutions to the surprise billing problem, in which patients undergoing procedures at in-network hospitals receive unexpectedly high bills because one or more of their clinicians was out of network. Under both approaches, patients receiving surprise out-of-network bills would be “held harmless" and would only have to pay their portion of the bill at in-network rates. But how should the out-of-network physician be paid in this situation? Cassidy supports an arbitration approach, similar to one being used in New York state. Under that approach, if an out-of-network provider receives a payment that's less than they think is fair, the provider and the insurer will go to a dispute resolution system and to arbitration. "There is a period of negotiation which could occur, but if they can't settle on a bill, [the arbiter] would choose one or the other, and the loser pays for the arbiter," Cassidy explained. "New York does it quite successfully." "The other competing proposal is based on what's done in California ... [but] I don't think California is very pleased with how this is going," he continued. "I'm told insurers can go to the doctor and say, 'This is our rate; if you don't like it, you're out.'" The rate is based on a multiple of Medicare rates, he added. “I'm told that California put up $300 million to attract physicians; if you have a hard time attracting physicians, there's something going on," said Cassidy. "I will tell you what we learned -- yes, frankly there are bad actors on the physician side, but there are also bad actors on the insurer side who, as a business practice, stay out of network with physicians," said Cassidy. "Or they will negotiate with the hospital but not negotiate with the physicians, or will negotiate with the specialist such as an anesthesiologist ... and give them nice rates for [managing] pain, but very low rates for administering anesthesia, but then take that anesthesia rate given to the pain doctor who never gives gas, and apply it to the folks who actually do. All these tricks that are played, and in this, they manipulate the system." "Most [plans] are attempting to get a good working relationship. In every group, there's about 5% that do it in a way where you could look at it objectively and say that's not fair at all," he added. Source: https://www.medpagetoday.com/practicemanagement/reimbursement/82717