Shenanigans ahead of Surprise Billing legislation

[lane]

This was sent to 50+ providers in North Carolina from BCBS (and verified). Pay attention to what the payors will do even before SBL takes effect. They can basically control QPA, so they can control the “fair market” rate, and will demand practices reduce their rates to stay in network or face arbitration to be paid their “fair market” rates set by QPA.
Please take time to contact your local societies and legislators so they may apply pressure to delay the rollout of SBL and revisit the rules being written.

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Members don't see this ad.

 

[BLADEMDA]

Congressional Doctors Lead Bipartisan Revolt Over Policy on Surprise Medical Bills - KFF Health News

Congress last year shielded consumers from unexpected out-of-network charges, but hospitals and doctors have decried the arbitration plan put forward by the Biden administration for negotiating these bills as favoring insurers. More than 150 members of the House agree.

khn.org

The consequences, opponents of the rule argue, would be a process that favors insurers over doctors, and pushes prices too low. They also argue that it would harm networks, particularly in rural and underserved areas, because it gives insurers incentive to push down the rates they pay to in-network providers. If the in-network rates are lower, then the default rate in arbitration is also lower.

 

[GassYous]

Man the legislation hasn't even gone into effect yet and they are putting on the screws as they jack up premiums and make billions. This country is rapidly going into the ****ter.

 

[coffeebythelake]

View attachment 345913
This was sent to 50+ providers in North Carolina from BCBS (and verified). Pay attention to what the payors will do even before SBL takes effect. They can basically control QPA, so they can control the “fair market” rate, and will demand practices reduce their rates to stay in network or face arbitration to be paid their “fair market” rates set by QPA.
Please take time to contact your local societies and legislators so they may apply pressure to delay the rollout of SBL and revisit the rules being written.

What bitches
Insurance companies

 

[gasdoc77]

There has to be some point at which a trailblazing physician (or group) will partner with a hungry lawyer and make a strong (successful?) argument for why physicians, now mostly employees, can unionize.

 

[Cookie]

I wonder if the people who work for AMCs are concerned at all about this ! My understanding is going out of network is the main negotiating tactic that AMCs use when negotiating new rates with insurance companies , if this goes away I am not sure how much leverage they will have.

 

[deleted941485]

View attachment 345913
This was sent to 50+ providers in North Carolina from BCBS (and verified). Pay attention to what the payors will do even before SBL takes effect. They can basically control QPA, so they can control the “fair market” rate, and will demand practices reduce their rates to stay in network or face arbitration to be paid their “fair market” rates set by QPA.
Please take time to contact your local societies and legislators so they may apply pressure to delay the rollout of SBL and revisit the rules being written.

They are throwing groups that have been with Ins for years OON on bull**** negotiation tactics. If they take the rates great, if not they'll have to come back in network and accept the lower rates anyway. They are killing PP which probably would have worked for less than they paid the AMCs. What happens if they are OON and patient is coming for elective procedure can you get payment in advance? is it a surprise bill if you tell them ahead of time?

 

[Blockit]

No, but the letter says that they are doing this to reduce the premiums for policyholders. Why would someone assume they keep that money for themselves?

😂🤣

 

[GassYous]

No, but the letter says that they are doing this to reduce the premiums for policyholders. Why would someone assume they keep that money for themselves?

😂🤣

Oh really because my premiums went up over 10% last year and over 20 this year so...

 

[Mman]

No, but the letter says that they are doing this to reduce the premiums for policyholders. Why would someone assume they keep that money for themselves?

😂🤣

that was the first thing I noticed. Those insurance companies are always all about the policy holders first and foremost!

 

[deleted941485]

that was the first thing I noticed. Those insurance companies are always all about the policy holders first and foremost!

I love that they said it twice...just to drive home the point that its all about the policy holders. Scum bags...they know exactly how to play the system.

 

[BlueRug]

So how badly is this going to hit PP? Is this a minor blip or total destruction?

 

[<(^_^)>]

They are throwing groups that have been with Ins for years OON on bull**** negotiation tactics. If they take the rates great, if not they'll have to come back in network and accept the lower rates anyway. They are killing PP which probably would have worked for less than they paid the AMCs. What happens if they are OON and patient is coming for elective procedure can you get payment in advance? is it a surprise bill if you tell them ahead of time?

Yup I mentioned this in a past comment. If the bill goes into effect without any change I don’t see how any AMC will survive at all. The only way they made it “work” was better negotiation of rates. Without that they just want to skim 20% off the top without any value add.

I expect (if no changes are made) there will be a pretty dramatic decline in AMC, followed by a rise in subsidies and/or hospital employed positions. Rural access to care in general will decline pretty significantly without subsidies.

The only entity that can negotiate with insurance companies now are hospital health networks, which can simply say “then you can’t be seen for any care/elective procedure in our service area” which in some cases is a pretty huge area with majority of hospitals under their control.

 

[deleted941485]

Yup I mentioned this in a past comment. If the bill goes into effect without any change I don’t see how any AMC will survive at all. The only way they made it “work” was better negotiation of rates. Without that they just want to skim 20% off the top without any value add.

I expect (if no changes are made) there will be a pretty dramatic decline in AMC, followed by a rise in subsidies and/or hospital employed positions. Rural access to care in general will decline pretty significantly without subsidies.

The only entity that can negotiate with insurance companies now are hospital health networks, which can simply say “then you can’t be seen for any care/elective procedure in our service area” which in some cases is a pretty huge area with majority of hospitals under their control.

Well they kill small PP and they kill mega AMC BS...so now the hospital will do the negotiating.

 

[BLADEMDA]

AMCs are better off dead. They are just leeches anyway. Better to work for a hospital or a university where they all must compete for our services. This will. Open up many more opportunities as each system competes for talent.

 

[aneftp]

it pertains to emergency services out of network. On an average how many patients are emergency out of network as a percentage of all anesthesia billing? I surmise a small less than 5%.

So elective out of network billing cases just won’t be done and everyone has to come to the table. So playing devils advocate. The bigger amc will demand even more money from the insurers to be in network. The bigger get bigger.

Say usap Texas holds 30-50% of market share? (I’m just guessing in Dallas?). They could give the big FU to insurance companies if insurance companies won’t come to the table to negotiate a reasonable in network rate. The bigger the market share the less leverage insurers have over these amc.

Than it becomes a public relations disaster for the insurance companies once the ads go out how much their executives make.

The hospitals will also put big pressure as well as many are saying services will be cut if anesthesia or ER isn’t in network cause hospitals are dealing with mom and pop anesthesia or er services. They are dealing with huge companies that service anesthesia and emergency medicine. So they can’t really throw these amc out the door quickly.

 

[BLADEMDA]

Hospital CEOs will realize AMCs hurt their business model with insurance companies. This Creates an environment where hospital and health systems are better off employing ER and anesthesia. While it is possible AMCs gain market share next year I think the opposite is much more likely. The HCA model is the future. Direct employment.

 

[BLADEMDA]

Under the notice and consent process, an out-of-network provider must notify a patient of its out-of-network status and obtain the patient’s written consent to receive out-of-network services more than 72 hours before the service is delivered. The goal of such an exception is to allow patients who wish to do so to choose an out-of-network provider when a substantive choice exists. The law also establishes that there is no notice and consent exception allowed for services where patients are typically unable to select their specific provider. This “no exception group” is defined as any service relating to emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic testing, and those provided by assistant surgeons, hospitalists, and intensivists. The Secretary of Health and Human Services (HHS) has the option to add to this list over time and to remove certain advanced diagnostic laboratory test

 

[nimbus]

it pertains to emergency services out of network. On an average how many patients are emergency out of network as a percentage of all anesthesia billing? I surmise a small less than 5%.

So elective out of network billing cases just won’t be done and everyone has to come to the table. So playing devils advocate. The bigger amc will demand even more money from the insurers to be in network. The bigger get bigger.

Say usap Texas holds 30-50% of market share? (I’m just guessing in Dallas?). They could give the big FU to insurance companies if insurance companies won’t come to the table to negotiate a reasonable in network rate. The bigger the market share the less leverage insurers have over these amc.

Than it becomes a public relations disaster for the insurance companies once the ads go out how much their executives make.

The hospitals will also put big pressure as well as many are saying services will be cut if anesthesia or ER isn’t in network cause hospitals are dealing with mom and pop anesthesia or er services. They are dealing with huge companies that service anesthesia and emergency medicine. So they can’t really throw these amc out the door quickly.

One of the strategies that anesthesia groups have used to get competitive rates was to refuse signing bad contracts and deliberately become out of network. Now that OON charges are capped, that strategy will be less effective. It’s not just emergency cases.

 

[BLADEMDA]

Furthermore, the U.S. Supreme Court effectively closed any pathways to appealing arbitrators' decision in a 1984 landmark case. Now, some good news for insurance companies: under a preliminary rule the feds issued in October, an arbitrator must select the settlement proposal closest to what's called the Qualifying Payment Amount (QPA), which is the insurer's median contracted rate.

As I see it, the bad news for some providers -- whether they're ambulance operators or anesthesiologists -- is that this system encourages insurers to lowball their settlement offers. For a provider to receive more than the QPA, he or she must provide evidence that "clearly demonstrates that the QPA is materially different from the appropriate out-of-network rate."



In the end, the system favors larger insurance companies holding contracts with larger health systems and provider groups, which they favor because they can offer their customers larger in-network plans with more participating physicians and other providers. Similarly, as a rule of thumb, larger provider groups can settle for smaller reimbursements knowing they can count on larger patient volumes generated by their affiliation with the big insurers. Moreover, larger groups possess greater resources to challenge QPAs through time-consuming research and presentation.

 

[lane]

Hospital CEOs will realize AMCs hurt their business model with insurance companies. This Creates an environment where hospital and health systems are better off employing ER and anesthesia. While it is possible AMCs gain market share next year I think the opposite is much more likely. The HCA model is the future. Direct employment.

You assume insurance companies have not, and will not, do the same with major hospital systems. United was out of network with Houston Methodist last year and it won’t be the last time a major carrier plays chicken with a major system.

The states’ departments of insurance will need to look closely at the insurance companies to determine whether they actually offer an adequate network. That’s the only real lever any practice has against their games. The insurance companies won’t care until next year’s enrollment period opens, and even then it’ll likely lag by a year before they get enough kickback from employers.

AMCs will likely be the only entities to have the resources to fight the QPA. I expect they’ll likely continue to grow as smaller groups are unable to maintain their rates and cannot afford to go through a rather unfair arbitration process (at least as the rules currently stand)

 

[dannyboy1]

Can someone explain the legal underpinnings of the no surprises act. How can the federal government mandate that I, a private citizen, must accept a certain (undetermined) amount as compensation for my time and service. This law applies not only to emergency cases where the patient really has no choice, but also to completely elective outpatient procedures. How can this be legal?

 

[BLADEMDA]

Can someone explain the legal underpinnings of the no surprises act. How can the federal government mandate that I, a private citizen, must accept a certain (undetermined) amount as compensation for my time and service. This law applies not only to emergency cases where the patient really has no choice, but also to completely elective outpatient procedures. How can this be legal?

Seriously? Have you ever looked at CMS? The govt. has passed laws making it illegal to balance bill Medicare patients. You must accept the reimbursement they set even if it is 1/4 your usual fee from private insurance (in network). Sure, you can opt out of CMS but that's not possible for 99% of anesthesiologists due to the nature of our work.

Now, you are complaining the govt. doesn't have the right to prevent you from balance billing a patient who is "in network" at your facility? If the reimbursement rate is too low then you have to fight the insurance company in arbitration. AMCs only have the "upper hand" over private groups because they get higher rates from the insurance companies. Now, they must use their size and attorneys to to fight those same insurance companies who surely will try to lower those rates to the level of the typical in network rate of $70 per unit. Typically, AMCs charge $100-$130 per unit to be in network with insurance companies. Most private groups get $65-$85 per unit. Insurance companies will try to reduce that number to $50-55 for private groups and $80 for the AMCs. This will take 2-3 years to pan out and see which side wins. There will be a lot of legal fees, arbitration fees and test cases across the nation. I doubt most private groups can deal with this process and thus, will be forced to accept $50 per unit. AMCs will use this chaos to swallow up groups at lower acquisition costs but, in the short term they too will go without a lot of revenue.

The bigger hospital systems are the ones most able to handle this entire process and remain in network. I suspect they will accept $50 per unit for anesthesia. I also expect most private groups are gong to feel this reduction in reimbursement by the Spring of 2022. Please realized that if they offer you $90 per unit in 2022 they may offer you $80 per unit in 2023 if the arbitration cases are going their way.

In the end, both AMCs and private Groups will see a reduction in the revenue from insurance companies. The question is how much reduction.

 

[Southpaw]

Health ins ceo salaries are going to skyrocket over this. Think of all the bonus money this will create for them!

 

[aafisahar]

Man the legislation hasn't even gone into effect yet and they are putting on the screws as they jack up premiums and make billions. This country is rapidly going into the ****ter.

america has basically always been a con-game to make as much money as possible before whatever industry you're in goes tits up (oil, gas, medicine, pharmaceuticals, finance, energy, insurance, etc). That people occasionally benefit at the same time is a bug, not a feature.

 

[deleted941485]

They are gonna make you piss your time and money away in arbitration.

 

[<(^_^)>]

I wonder if we will see consolidation within AMCs. Yes, AMCs could sweep in and buy private groups but I could also easily see them joining forces (or buying fledgling AMC groups) to gain leverage. In fact I almost see this as more likely. I expect there might be a lot of “swaps” between AMCs to build up territorial dominance in particular cities. Not like any company could be broken up for being “too big” these days. Usually in turmoil within an industry you don’t see people taking more risk on, but trading territory (0 additional risk/exposure) or mergers are common.

Either way the best way to approach this as an individual is the same: save aggressively until you have enough money to walk away if you felt like it.

 

[pastafan]

No, but the letter says that they are doing this to reduce the premiums for policyholders. Why would someone assume they keep that money for themselves?

😂🤣

Because they don't mention it on their web site:

Blue Cross NC was founded as a nonprofit Medical and Hospital Services Corporation. Although we are structured as a nonprofit (no shareholders) corporation, the company is fully taxed and in 2019 incurred $431.0 million in federal, state and local taxes.7 Blue Cross NC has not been tax exempt since 1973 (State) and 1986 (Federal) and it is not a 501(c)(3) charitable organization.

Because we don't have shareholders, our net income is invested back into the company into things such as health programs for our members, customer service improvements and technology. It also contributes to our reserves, which represent the safety net for our customers in the event of an economic downturn or public health emergency.

 

[lane]

Anesthesiologists allege BCBS of North Carolina using 'strongarm tactics' ahead of No Surprises Act rollout

The American Society of Anesthesiologists issued a statement condemning BlueCross BlueShield of North Carolina's alleged abuse of the No Surprises Act to

www.beckershospitalreview.com

“
Nick Moran - Monday, November 22nd, 2021 Print | Email
The American Society of Anesthesiologists issued a statement condemning BlueCross BlueShield of North Carolina's alleged abuse of the No Surprises Act to "strongarm" clinicians and practices into network agreements.
The payer sent letters to anesthesiologists and other physicians demanding an immediate 10 to 30 percent rate reduction to accommodate the No Surprises Act rollout in 2022, according to a Nov. 22 news release from the advocacy group shared with Becker's.
"Instead of expanding in-network access for patients, BlueCross BlueShield of North Carolina has demonstrated what we explained to Congress and the rule-making agencies would happen: Insurance companies will use their overwhelming market power and the No Surprises Act's flawed rules to push more physicians out of insurance networks and fatten their own bottom line," said Randall Clark, MD, president of the American Society of Anesthesiologists.
"Insurance companies are threatening the ability of anesthesiologists to fully staff hospitals and other health care facilities," he said. "Left unchecked, actions like these of BlueCross BlueShield of North Carolina will ultimately compromise timely access to care for patients across the country."
A BlueCross BlueShield of North Carolina spokesperson told Becker's that specialists in the state, including anesthesiologists, can charge upward of 500 percent more than what they charge Medicare patients.
"As a result, Blue Cross and Blue Shield of North Carolina ... sent letters to 54 of the most expensive provider practices in the state," the spokesperson told Becker's. "This is a small percent of the thousands of contracts we have with providers and hospitals across the state who have agreed to negotiate more reasonable rates."
"Blue Cross NC is pleased Congress took steps to protect patients from unfair and costly surprise medical bills, and we appreciate the opportunity to take patients out of the middle and negotiate directly with the most expensive for-profit providers," they said.”

 

[BLADEMDA]

Medicare is $21 per unit for 2022. So, yes Groups need to charge 400% of Medicare to remain viable and competitive in the market. 500% over Medicare is reserved for the biggest groups and AMCs.

To the lay person, 500% seems like way, way over-priced until the facts about the "Anesthesiology Medicare problem" gets fully explained. Typical misdirection and sleight of hand by Blue Cross.

 

[narcotics999]

Medicare is $21 per unit for 2022. So, yes Groups need to charge 400% of Medicare to remain viable and competitive in the market. 500% over Medicare is reserved for the biggest groups and AMCs.

To the lay person, 500% seems like way, way over-priced until the facts about the "Anesthesiology Medicare problem" gets fully explained. Typical misdirection and sleight of hand by Blue Cross.

The central problem is that medicare rate is too low. If you could get 35$ for medicare, 30$ for medicaid, we would do well with 2X for commercial insurance (heck, even 1.5X).

I will renew my ASA membership and donate if ASA starts to negotiate CMS rates.

 

[Mman]

The central problem is that medicare rate is too low. If you could get 35$ for medicare, 30$ for medicaid, we would do well with 2X for commercial insurance (heck, even 1.5X).

I will renew my ASA membership and donate if ASA starts to negotiate CMS rates.

ASA has nothing to do with CMS rates. It's the Relative Value Scale Update Committee (RUC) that helps determine physician reimbursement from CMS for various things. And it's a zero sum game. To get more for anesthesia, you have to get them (other physicians) to agree to take it away from other specialties. And you know how much everyone loves us!

 

[Mad Jack]

Overpriced Docs Mad Over New Surprise Billing Law

Overpriced anesthesiologists in NC are mad over new surprise billing law.

www.affordablecarenc.com

This popped up in my Facebook feed. This is the sort of garbage insurers are feeding to the public.

 

[nimbus]

Overpriced Docs Mad Over New Surprise Billing Law

Overpriced anesthesiologists in NC are mad over new surprise billing law.

www.affordablecarenc.com

This popped up in my Facebook feed. This is the sort of garbage insurers are feeding to the public.

And they’re winning.

 

[Mad Jack]

And they’re winning.

Oh they're killing it. It's depressing to watch, and shocking how far physicians have fallen that we're just going to let it happen

 

[BLADEMDA]

"Extortion has been a good business model for anesthesiologist in North Carolina for quite some time.

‍

But thankfully for patients, Congress put an end to that effective January 1."

 

[OneFellSwoop]

Here’s the board of this ‘noble’ coalition looking out for NCs patients…not biased at all

 

[PikminOC]

I guess now nurses for all anesthesia

 

[DoctwoB]

Blade is right though. This will favor consolidation into the large regional hospital/doc practices. Because if you work for UPMC, sutter, etc you are on the same networks as every other doc in the system, and they can just refuse to offer elective out of network care or demand up front cash payment for OON patients. So if insurance wants their patients to access that system (often a regional near monopoly), then they need to pony up.

 

[deleted941485]

Here’s the board of this ‘noble’ coalition looking out for NCs patients…not biased at all

View attachment 346420

I believe the radiology community has picked this up as well. They face the same issues.

 

[aafisahar]

Oh they're killing it. It's depressing to watch, and shocking how far physicians have fallen that we're just going to let it happen

consequence of americans getting ****ed on healthcare pricing and physicians being the face of it. Families with "good insurance" getting stuck with a 3k bill after something seemingly minor (ER visit, surgery, hospitalization), etc etc, are going to blame physicians as we are the face of healthcare and ostensibly do well for ourselves. Making 200k for most people in America (not everyone's friend's brother who makes 450k at google) is a mind-numbing amount of money. For physicians, it's less than minimum wage. So patients feel their expenses when they are most vulnerable are going to these high salaries, not realizing that insurance companies are robbing them blind. Insurance companies use propaganda to say they have amazing coverage and that most people love their private insurance as hedges against public options/universal healthcare, etc. This narrative is killing it for them.

 

[GassYous]

Overpriced Docs Mad Over New Surprise Billing Law

Overpriced anesthesiologists in NC are mad over new surprise billing law.

www.affordablecarenc.com

This popped up in my Facebook feed. This is the sort of garbage insurers are feeding to the public.

This sounds like it was written by a ten year old. But why is it that they don't mention that their premiums go up by over 10% every year? Or the billions in profit they are making from money that is supposed to go to paying for healthcare?

Amazing that the leaches from the system are winning this propaganda war against the people who actually provide the useful service that people need.

 

[deleted941485]

This sounds like it was written by a ten year old. But why is it that they don't mention that their premiums go up by over 10% every year? Or the billions in profit they are making from money that is supposed to go to paying for healthcare?

Amazing that the leaches from the system are winning this propaganda war against the people who actually provide the useful service that people need.

They are winning the propaganda war because they say oh you got a bill from your doctor? Well that's because the doctor is greedy and bad and were on your side! Heres the bill you have to pay.

Its hilarious, they shield them from less of the HC costs and put it on the patient and they manage to convince the patient that its the doctor whose ****ing them.

In regards to the article written by a 10 year old because that is precisely the point, they assume the the average joe patient reads at that level and understands little to no nuance. If anything its an insult to their intelligence and the best part is they don't even know it.

 

[Blockit]

This sounds like it was written by a ten year old. But why is it that they don't mention that their premiums go up by over 10% every year? Or the billions in profit they are making from money that is supposed to go to paying for healthcare?

Amazing that the leaches from the system are winning this propaganda war against the people who actually provide the useful service that people need.

The reason it appears to be written by a 10-year-old is because that’s what the bulk of the citizens of North Carolina understand.

 

[teacher2md]

Big loss for United in a Nevada lawsuit brought on behalf of TeamHealth's ER physicians.

Nevada Jury Finds UnitedHealthcare and Affiliates Guilty of Oppression, Fraud and Malice in its Conduct against Frontline Healthcare Heroes​

Check out these highlights:

• John Haben, the former head of United’s Shared Savings Program, confirmed United’s role in colluding with Yale University professor Zack Cooper to produce a controversial study used to promote the false view that TeamHealth engaged in balance billing. The study misled Congress into passing legislation giving insurers significant leverage over frontline providers.
• United exposed their members to surprise medical bills.
• Haben also stated under oath that United paid as little as 20% of the clinicians’ billed charges.
• United’s Shared Savings Program takes up to a 50% administrative fee on the difference between billed charges and United’s arbitrary payments.
• United often receives more money on their shared savings fee than they pay to the provider.

 

[aafisahar]

This sounds like it was written by a ten year old. But why is it that they don't mention that their premiums go up by over 10% every year? Or the billions in profit they are making from money that is supposed to go to paying for healthcare?

Amazing that the leaches from the system are winning this propaganda war against the people who actually provide the useful service that people need.

Remember, think how dumb the average American is and then realize half are stupider than that.

 

[Mman]

Remember, think how dumb the average American is and then realize half are stupider than that.

at least give Carlin the credit

 

[nimbus]

Remember, think how dumb the average American is and then realize half are stupider than that.

Sorry to get off-topic but are you talking about parents who buy a Sig Sauer 9mm for their troubled teen boy? Merry Christmas!!

 

[narcotics999]

ASA responded, a welcome move:

American Society of Anesthesiologists accuses BCBS North Carolina of abusing No Surprises Act

ASA interprets BCBS' intent as improving its negotiating position against physician practices in the dispute resolution process.

www.healthcarefinancenews.com