Surprise Medical Bills And Balance Billing

Treat the Symptoms or the Virus?

There has been a lot of talk about “Surprise Medical Bills” and “Balance Billing” in the news lately, but is this really the problem or might we be missing something? We’ll examine the causes behind this troubling trend and see if we can find a way forward for providers and patients alike in the final installment of the three-part blog series by QMC and industry expert, Ed Marasco.

Ed Marasco, MPM, CMTE, EMT-P (Ret.) is Vice President of Business Development at Quick Med Claims and a respected leader in the medical transportation industry. Ed has extensive experience in the areas of medical transportation billing and reimbursement policy gleaned from years as an air medical EMT-P and his time at QMC. He has served on several national committees and recently participated in the Negotiated Rulemaking Process to develop the current Medicare Ambulance Fee Schedule.


Part 3: Finding a Cure

Early in 2019, the Insurance Lobby, with the support of patient advocacy groups, were making great progress toward a legislative fix. However, late in 2019, the provider/supplier side of the healthcare system responded with a compelling campaign of their own and the legislative solution has been further complicated by current events.

Surprise Medical Bills And Balance Billing Part 3 Understanding The Disease

Current Status of Treatment

With 2019 in the rear-view mirror, 2020 arrived with a very complex political environment. While the folks in Washington were busy ramping up for a Presidential election year and trying to address a number of other longstanding legislative initiatives, the COVID-19 Pandemic arrived on the scene. Until the US outbreak in March, there were several other distractions at the Federal level:

  • Impeachment
    While there was some level of cooperation among political parties in Congress throughout 2019, impeachment cast a shadow over any chance for bipartisan efforts in 2020.
  • Overhaul to the Stark Law (1989)
    The Stark Law has created some barriers to the evolution of integrated healthcare systems and some tenets of value-based solutions. There seemed to be a strong desire to reform some of its basic principles in 2020.
  • Drug Price Legislation
    In an election year, both parties seemed to be hanging their political hat on initiatives that would have a positive financial impact on voters. The issue of drug pricing has become a lightning rod matter because of the individual economic impact on virtually every American.
  • Price Transparency Rule
    The movement toward price transparency has significant support but the matter is significantly more complicated than envisioned by lawmakers.
  • Surprise Medical Billing
    The legislation appeared to be a bipartisan slam dunk at one point in 2019, but now is in serious jeopardy of dying. As recently as the early part of February 2020, the House Ways and Means Committee published its own version of legislation (following earlier releases by the House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions Committee). Both the House AND Senate have advanced legislation in this regard. Unfortunately, provider and supplier stakeholders initiated an all-out assault on the legislation during the summer recess, while passage of legislation became mired in election year politics.

Then, there were crisis issues to address via the CARES Act:

  • Funding and Support
    The CARES Act and related government programs are providing some much-needed support for healthcare providers/suppliers, including the medical transport community.  The fact that legislators were willing to tie receipt of these funds to a commitment NOT to balance bill should provide some level of evidence that this issue is still very much alive. Neither party would risk the political fallout from holding up the CARES Act over an issue like this unless they believed the political upside was substantial.
  • Attestations
    Providers/Suppliers accepting this relief are required to make a commitment to give up their right to balance bill for any services related to COVID-19 for an unspecified period of time. Widespread acceptance of the funds (and relinquishing of the right to balance bill) is tantamount to testing a “treatment.” In a way, we are participating in a clinical trial of sorts without appreciating it!

In Search of the Treatment and a Vaccine

These are unprecedented times and one thing is for certain, healthcare delivery systems will never be the same as they were prior to the COVID-19 Pandemic. However, the issue of Surprise Medical Bills and Balance Billing remains an illness without a cure or a vaccine.

There are several items unfolding that may lead us to both:

  • Cost Analysis
    Many of the rub points in the various solutions that have been presented revolve around the economic considerations for each of the constituent groups. Getting to a fair and equitable reimbursement will certainly be the key to eliminating the need for Balance Bills and should drive providers/suppliers toward in-network status. Understanding the cost of providing these valuable services is a critical component of developing a successful treatment. With the current cost data collection efforts by CMS on the ground medical transport side of the business, a precedent is in place. It’s conceivable that some form of cost reporting and analysis might be an important aspect of the treatment moving forward, considering there is already an element of cost reporting in the CARES Act requirements.
  • Air Ambulance Patient and Billing Advisory Committee Update
    Air Ambulance Patient and Billing Advisory Committee (AAPB) activities were another casualty of COVID-19. In the original timeline for the Committee, work was to be completed by July 2020, a date COVID-19 summarily dismissed. Prior to the hiatus, it was clear that this matter was very much at the forefront of the Committee’s deliberations. With the fallout from the Pandemic easing a bit, the AAPB is once again pressing forward. Providers/Suppliers should follow the work of the Committee very carefully because the findings will most certainly include recommendations in this area.
  • Airline Deregulation Act (ADA)
    Any treatment that is proposed will need to include reconciliation with the Airline Deregulation Act (ADA) if it is going to apply to air medical transport. There has been an abundance of options considered to address the application of the ADA, including some discussion at the AAPB regarding the separation of billing and reimbursement for aviation and medical services.

Summary

Any effective treatment for Surprise Medical Bills and Balanced Billing will likely require both a Treatment for the symptoms and a true attack on the underlying virus… a Vaccine. The short-term treatment will likely require reimbursement calculated as a percentage of COST. Longer-term, the vaccine will require a new economic model for the funding of medical transport services. A key element of any vaccine will require more appropriate reimbursement levels for both Medicare and Medicaid beneficiaries which would eliminate the need for cost-shifting. Improved reimbursement, along with a reduction in the under/uninsured population would go a long way toward solving this challenge.

The ability of the healthcare system to align the interests of patients, employers, payors with providers/suppliers will go a long way toward effectively deploying a cure.

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