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The American Society of Anesthesiologists has accused BlueCross BlueShield of North Carolina of abusing new federal law designed to protect patients from off-grid bills.
Essentially, the ASA is highlighting what it sees as proof of its prognosis in Congress: that insurers would use loopholes in the No Surprises Act to leverage their market power in a way that push doctors out of the networks. insurance in order to boost their finances. The group considers the actions planned by the BCBS as the first indicator of this trend and is specifically concerned about the ability of anesthesiologists to fully staff hospitals.
Letters sent by BCBS to anesthesiology and other medical practices in the state threaten contract termination and the status of doctors in the network unless doctors immediately agree to payment reductions ranging from 10 to more than 30%, according to the ASA. The implementation of the No Surprises Act is cited in the letters as the impetus for the cuts.
The ASA interprets the BCBS’s intention as an improvement in its negotiating position against the practices of community physicians in the dispute resolution process outlined in the recently released Interim Final Rule implementing the legislation.
BCBS, for its part, said federal law now allows for a significant change in its contracting approach with emergency service providers, hospital providers and air ambulance services.
“Where previous state law could result in an obligation to pay the full fee if no contract is in place, the new law sets reasonable limits for payment at the network’s midpoint rate,” BCBS wrote in his letter. âWhere Blue Cross NC may have already contracted at what we considered to be an inflated rate which is at least slightly lower than the fee in order to avoid paying the full rate, we are now able to look for a contract at a rate more in line with what we consider to be a reasonable market rate. “
Although the exact eligible payment amounts are not yet available, pending the finalization of the No Surprises Act rules, BCBS interprets the interim final rules as providing sufficient clarity to justify a significant reduction in contract rates.
BCBS said that if it is unable to establish on-grid tariffs more in line with “a reasonable market rate,” the plan is to terminate agreements in which the resulting off-grid QPA “would reduce medical expenses for the benefit of our clients’ overall premiums.
To this end, BCBS is seeking an immediate reduction in tariffs as part of the trade deal, which the insurer says would give it leeway to negotiate final tariffs in light of the upcoming amounts of the. APQ. The interim tariff reduction, the BCBS said, would mean the insurer would not need to terminate “outlier” contracts quickly in order to avoid payment levels above default.
The insurer’s proposal is a 15% reduction by December 15. If accepted, BCBS has said it will make a rate change. If no agreement is reached, the organization plans to move forward with terminating the contracts.
WHAT IS THE IMPACT
The No Surprises law, passed in December 2020, was designed to protect patients from off-grid surprise bills. It will come into force in January 2021.
The law intends to settle payment disputes through an impartial arbitration system. But the ASA claims that recent rules enacted by the departments of Health and Human Services, Labor and Treasury create a system that unfairly favors insurance companies. This week, he cited the BCBS letters as evidence of bias.
âInstead of expanding network access for patients, BlueCross BlueShield of North Carolina demonstrated what we explained to Congress and regulatory agencies would happen: Insurance companies will use their overwhelming market power and the flawed rules of the No Surprises Act to push more physicians out of insurance networks and fatten their own bottom line, “said ASA President Dr Randall Clark.” Insurance companies threaten the ability of anesthesiologists fully staffing hospitals and other health care facilities. Left unchecked, actions like those of North Carolina’s BlueCross BlueShield will ultimately compromise timely access to care for patients across the country. “
ASA had previously asked the US Department of Justice to tackle what he called âanti-competitive tactics by insurance companiesâ.
THE BIGGEST TREND
Surprise billing occurs when a patient sees an off-network provider during an emergency, or in a non-emergency case where a patient sees a networked provider but receives care from an off-grid provider, such as a anesthetist.
In addition, some providers charge patients the difference between what the insurer pays and the total amount for out-of-network care. Invoicing the balance is already prohibited in some states.
Surprise billing has left many patients vulnerable to financial burdens during a nationwide pandemic. Research shows that 41% of insured adults nationwide have been surprised with a medical bill in the past two years, and two-thirds of adults are concerned about their ability to pay an unexpected medical bill.
Congress passed the No Surprises Act in December 2020, which prohibits most off-grid surprise billings for plan years beginning in 2022. Specifically, it requires plans to enforce on-grid cost sharing and prohibits off-grid providers. network to charge the balance. on surprise medical bills.
The law, however, does not apply to ambulance bills – which is important, as up to 1.5 million privately insured patients are brought to an emergency room by an ambulance and may be at risk of receive a surprise medical bill every year, according to the Kaiser Family Foundation.
While the No Surprises Act does not address surprise ambulance bills, it does require that a federal advisory committee meet to review and recommend options to protect patients against them.
This week, the government released a report showing that millions of Americans with private health insurance are experiencing some kind of surprise medical billing. Surprise medical bills are relatively common among privately insured patients and can on average more than $ 1,200 for services provided by anesthesiologists, $ 2,600 for surgical assistants and $ 750 for childbirth care, according to the report of the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.