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Insurers, providers spar over solution to surprise medical bills

America's Health Insurance Plans called on Congress to set a fixed reimbursement rate based on what insurers pay in a region.

Susan Morse, Senior Editor

Providers are pushing back against an insurer proposal for legislation to set reimbursement rates to avoid surprise medical bills.

In a letter to Senate and House leaders this week, America's Health Insurance Plans and 16 other organizations asked Congress to pass legislation setting reimbursement rates that would not increase premiums by basing amounts on market rates determined by "reasonable, contracted amounts" paid by health insurers in a geographic area, or a percentage of Medicare.

The American Hospital Association and the Federation of American Hospitals pushed back against the proposal in their own statement.

"Not only is it a dangerous precedent for the government to start setting rates in the private sector, but it could also create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks," said AHA President and CEO Rick Pollack and the Federation of American Hospitals President and CEO Chip Kahn. "That solution is simple: patients should not be balance billed, and they should have certainty regarding their cost-sharing obligations based on an in-network amount."

In February, the AHA sent a letter to Congress saying providers should not balance bill, that is, bill a patient beyond his or her cost-sharing obligations.

Also, Pollack and Kahn said, it is essential that insurers and providers retain the ability to negotiate appropriate payment rates.

AHIP and others recommended avoiding the use of "complex, costly and opaque arbitration processes that can keep consumers in the middle and lead to higher premiums."

WHY THIS MATTERS

Congress has been working on legislation to protect patients from surprise medical bills when consumers see - many times unwittingly - an out-of-network physician.

Patients are often left with thousands of dollars in unexpected medical bills.

WHAT ELSE YOU NEED TO KNOW

AHIP and the other organizations also recommended that doctors be prohibited from sending a surprise medical bill to patients in cases of emergency, involuntary care, or instances where the patient had no choice in provider.

The groups also asked that providers be required to inform patients of their doctors' network status and possible options for seeking care from a different doctor, but not require patients to consent to out-of-network care.

Additionally, AHIP and ensure that these protections apply to all health plans, including self -funded plans governed by ERISA, so consumers are protected regardless of coverage type.

In sending the letter to Senate and House leaders, AHIP was joined by the BlueCross Blue Shield Association, American Benefits Council, the Council of Insurance Agents and Brokers, the Food Marketing Institute, the National Retail Federation and others.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com