ACA Senior VP of Government Relations John Falardeau recently spoke with HealthLeaders Media about a new interpretation of the PPACA by a trio of federal agencies—the departments of Labor, Treasury, and Health and Human Services—requires provider networks to include doctors of chiropractic medicine or coverage for chiropractic services at in-network rates. “We are calling this a game-changer,” Falardeau told the publication.
[quote_center]As narrow provider networks become more widespread, healthcare payers and regulators are focusing on the ground rules for out-of-network care payments. Chiropractic and telemedicine practitioners may benefit.[/quote_center]
Key questions about narrow networks are becoming clearer.
With exclusionary underwriting such as pre-existing condition culling outlawed under the Patient Protection and Affordable Care Act, provider network design has emerged as a key tool for payers to control the quality and cost of healthcare services.
The first stage in the evolution of these so-called narrow networks focused on the adequacy of provider networks, with regulators setting service accessibility standards for patients such as travel distance limits.
As state and federal officials finalize provider-network adequacy standards, billing for out-of-network healthcare services appears destined to dominate the next evolutionary stage of narrow networks.
Robin Gelburd, president of New York-based FAIR Health, says establishment of ground rules for out-of-network care should be a top transparency goal in the healthcare industry.
“Out-of-network care is squarely in the spotlight now, but there are two major prongs to that discussion—elective out-of-network care and ‘the surprise bill.’ In elective out-of-network care, there often is a unique issue or a pre-existing relationship with a physician who is no longer in the payer’s network. When there is a lack of transparency in these elective out-of-network cases, there are unexpectedly high out-of-pocket costs for patients. If there is going to be cost-sharing for this care, it’s better for patients to know that before they get a service,” Gelburd told me recently.
“With the surprise bill, a patient thinks that a service is covered at the in-network rate, but the bill includes an unexpected out-of-network fee. This is the exacerbation of the times.”
FAIR Health is a not-for-profit corporation founded in 2009 to gather and leverage payer claims information. The organization has taken a leading role in healthcare transparency efforts, including provision of data used to set pricing benchmarks for New York’s recently adopted healthcare transparency law.
Gelburd says the Empire State’s healthcare transparency law, which includes consumer protections for patients who seek out-of-network services, reflects a growing regulatory trend.
“We’re starting to see ripple effects across the country, with states experimenting. Protective provisions are needed for consumers, and those protections will vary from state to state,” she says, noting that Connecticut has established out-of-network billing standards for emergency care. “The New York law is becoming the national model. Connecticut, New Jersey, and Texas are all looking at regulating surprise bills. It’s a necessary outflow of a changing marketplace.”
Gelburd says healthcare industry stakeholders who resist the transparency trend are taking a high-risk gamble. “The consumers are not in the chorus line anymore. … They have been pushed into the spotlight, and they are asserting their voice.”
New Jersey is another state on the front lines of clashes over billing for out-of-network care.
In a commissioned study that Horizon Blue Cross Blue Shield of New Jersey released in March, the Newark, NJ-based payer calls for limits on the prices that providers can charge for out-of-network care.
“Health plans build provider networks both to manage costs and to promote higher quality care for their members. These relationships are also critical building blocks needed to support evolving accountable and coordinated care structures that aim to promote and reward high-value patient-centered care rather than high-volume fee-for-service medicine,” the study concludes. “Current New Jersey rules that apply when health plan members involuntarily utilize out-of-network providers, with no limit on what out-of-network providers can charge, create an incentive structure that is at odds with these goals.”
Unreasonable billing for out-of-network services is costing Horizon BCBS hundreds of millions of dollars, the study finds. For out-of-network service claims in 2013, Horizon BCBS would have saved $497 million if the claims had been paid at 150% of the Medicare rate rather than paid at 100% of the out-of-network charge.
In November, Hartford, CT-based Aetna filed suit against a staff physician at Monmouth Medical Center in Lakewood, NJ. The lawsuit, which was filed in the Superior Court of New Jersey, claims the physician filed excessive claims for treatment of abdominal pain totaling $31,939. The doctor’s bills exceeded the Medicare rate by nearly $30,000, according to Aetna. The suit also claims the doctor failed to inform his patient that he was not in Aetna’s provider network.
Aetna’s complaint in the lawsuit accuses the doctor of pricing gouging for out-of-network services: “After Aetna properly paid Defendant the fair value for his services and the accepted rate for similar services in the community by providers in Defendant’s area of practice, Defendant sought to exploit and to gouge [the patient] by billing the member for the difference between his charges and what Aetna paid to him—a practice commonly referred to as ‘balance billing’.”
The patient was billed $10,635, according to Aetna’s complaint.
The defendant in the case, Sanjay Bhagat, MD, says the lawsuit was dismissed. He declined to comment about details of the case.
Chiropractic, Telemedicine Could Benefit
While the out-of-network frontier is generating friction over billing for services, some physicians and their patients are mutually benefiting from the rigorous regulatory review of provider networks for adequacy and consumer protection.
A new interpretation of the PPACA by a trio of federal agencies—the departments of Labor, Treasury, and Health and Human Services—requires provider networks to include doctors of chiropractic medicine or coverage for chiropractic services at in-network rates.
“We are calling this a game-changer,” John Falardeau, senior vice president of government relations at the American Chiropractic Association, told me recently. “We are thrilled these three agencies went back and gave a better take on guidance for payers. We saw a lot of confusion before.”
He says chiropractic physicians have struggled for decades to be included in provider networks. “It’s always been a challenge. It’s certainly something that many of our providers have become so fed up with that they have gone to cash-only services.”
The struggle for inclusion has generated positive results for chiropractors and their patients, Falardeau says. “Chiropractic care has become much more mainstream. You can find it in most health plans. For plans on the new [PPACA] exchanges, 90% of plans cover chiropractic.”
Tyler Brannen, health policy analyst at the New Hampshire Insurance Department, says telemedicine could be the final out-of-network frontier for healthcare regulators.
“There is massive growth in telemedicine, which could create coverage issues. Is it covered as a telemedicine service or as a physician who is using telemedicine to provide a service? Is a telemedicine visit covered or is it out-of-network? How do you cover telemedicine services in the home?” he asks.
There may be a couple years of awkward puberty ahead, but provider networks and the rules that govern them are taking their final shape.
Source Health Leaders Media