Issue link: https://beckershealthcare.uberflip.com/i/702654
61 61 REVENUE CYCLE MANAGEMENT emergency physicians said they believe health insurance companies are misleading patients by offering affordable premiums for policies that actually have very little health coverage, according to a recent ACEP survey. 13. Payer and providers break network ties over reimbursement rates. e news has been rife with payer-provider contract disputes over the past two years, largely centered on unfair reimbursement rates that shi financial responsibility onto patients and physicians. Last year, Carondelet Health Network in Tucson, Ariz., accused Blue Cross Blue Shield of offering untenable reimbursement rates. Community Health System in Munster, Ind., severed ties with Anthem BCBS earlier this year, citing an inability to agree on fair and sustainable network costs, only to come to an agreement months later. As commercial payers continue to reduce reimbursement levels, to the point of not covering operating costs, "health insurance companies are driving physicians out-of-network," said Dr. Kaplan. 14. Payers are reducing reimbursements to out-of-network providers. Some disgruntled payers, upset by providers' extraordinary out-of-network rates, have continued to lower the amount they pay for out-of-network services — heaping more financial obligation onto patients. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News. 15. Payers have sued providers for "excessive" reimbursement rates. Some payers that have accused provider groups of charging outlandish rates for medical services have taken legal action. Aetna, for instance, sued a half dozen out-of-network physicians in the past few years, alleging gross overcharging for medical services. Aetna has also sued free-standing ERs for excessive facility fees. In 2014, Aetna filed suit against two Houston-area ERs in federal court, alleging the clinics committed fraud by forming misleading ties with hospitals in order to charge excessive facility fees to patients. 16. Patients are taking hospitals to court over balance billing practices. As an increasing number of patients face balance bills, many are questioning the legality and fairness of hospital balance billing practices. In a recent lawsuit brought by Martinsville (Va.) Memorial Hospital against a patient, a judge ordered the hospital accept 25 percent of its chargemaster rate as payment-in-full for emergency care provided to a patient with an out-of-network insurance. e patient's lawyer argued this payment was sufficient because the hospital accepts 25 percent of prices specified in its chargemaster as payment-in-full for services to uninsured patients. 17. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. ose in rural areas oen must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. For example, when Amy omson's newborn daughter was in heart failure, Ms. omson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time, her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio. Ms. omson received a $43,000 balance bill from Airli Northwest aer PacificSource contributed a policy cap of $13,000. 18. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider- based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high-deductible health plan. 19. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off- campus outpatient facilities. e legislation does not apply to existing outpatient centers that already engage in the practice, however. 20. e president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. e administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network. 21. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. e states of Illinois and New York have arbitration methods in place, and Washington and Pennsylvania are currently considering a similar resolution method. 22. New York has some of the strongest consumer protection laws. Under New York law, consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes. 23. Florida Gov. Rick Scott signed a bill banning surprise medical charges. e governor signed HB 221, which put new limits on balance billing. Under the bill, consumers cannot be charged more than the equivalent of in-network charges in emergencies and at other times where the patient has no real choice — such as an out-of-network anesthesiologist for a scheduled procedure at an in-network hospital, according to a Palm Beach Post report. e bill exempts ambulance services. 24. Washington State Rep. Eileen Cody (D-Seattle) sponsored a bill to prevent balance billing in 2017. Under HB 2447, if patients receive emergency care from their health plan's approved hospital, they would pay only the expected charges, according to a statement from Washington Insurance Commissioner Mike Kreidler. Also, any disputes over contracts or out-of-network fees would be worked out between the insurer and the medical provider or facility. 25. e extent of balance billing in Washington is a source of debate. e Consumer's Union estimates about one out of three Washingtonians with private insurance received a surprise medical bill in the past two years. However, the Washington Chapter of the American College of Emergency Physicians says it leaves less than 1 percent of ER patients with a bill that is more than $250, according to a KING report. 26. Lawmakers, consumer advocates and healthcare professionals are part of an ongoing discussion in California on how to curb balance billing. Under legislation recently reintroduced by California Assemblyman Rob Bonta (D-Oakland), consumers who go to an in-network facility but are treated by an out- of-network provider would only be charged what they would have been charged if the