Policy Making & Sausage

The Balance Billing Saga Continues in 2021: Part 2

By Ed R. Marasco, MPM, CMTE, EMT-P (Ret.)*

There is an old saying:

“The two things you never want to know about how they are made… public policy and sausage.”

The ingredients and process can be very alarming. This is the second installment of a multi part series following the policy efforts to end balance billing. In this article, we will address the work of the Air Ambulance Patient Billing Advisory (AAPB) Committee and its Subcommittees.

Subcommittee of Prevention of Balance Billing

This Subcommittee was comprised of consumer groups, DOT representatives, insurance industry representatives and transport industry representatives. Their recommendations included:

Policy Making & Sausage - The Balance Billing Saga Continues in 2021: Part 2

  • Federal legislation for mandatory, binding Independent Dispute Resolution (IDR) of disputes between out-of-network air ambulance providers and payors. Both payor and the air ambulance provider must protect the patient from paying more than the patients’ copay amount, coinsurance rate, and deductible through “hold harmless” provisions and prohibitions on balance billing. The system is also intended to encourage in-network participation.
  • That air ambulance providers and payors engage in contract network negotiations in a transparent manner for the purpose of agreeing on fair, reasonable, and market-based reimbursement rates.
  • The U.S. Department of Transportation (DOT) promulgate regulations for the collection of data to (a) improve understanding of air ambulance services, and (b) increase transparency of market conditions impacting air ambulance services, and (c) indirectly improve contract negotiation between payors and air ambulance providers and suppliers.
  • Legislation should be enacted to authorize the U.S. Department of Health and Human Services (HHS) to study Medicare rates for air ambulance services and to increase the reimbursement rates for air ambulance services, if warranted, upon conclusion of the study.

Subcommittee on Disclosures and Distinction of Charges

This Subcommittee was comprised of DOT representatives, HHS representatives, revenue cycle management professionals and transport industry professionals. Their recommendations included:

  • That the HHS conducts rulemaking to require payors to disclose air ambulance coverage, cost, and network information within Statements of Benefits and Coverage.
  • HHS conducts rulemaking to require entities that request non-emergency air ambulance transport to provide notice to consumers regarding potential transport charges that may not be covered by insurance.
  • HHS and other agencies conduct rulemaking to require payors and other agencies payors to disclose information to patients and providers explaining the payor’s denial of a claim for air ambulance charges and providing options for recourse. The Subcommittee also recommends that DOT conduct rulemaking to require air ambulance providers to explain the charges to patients as well as options for recourse.
  • Relevant stakeholders work together to develop best practices and standards for disclosures of information on subscription programs by air ambulance providers to consumers, including coverage information.
  • DOT conducts rulemaking to require air ambulance providers to disclose on their websites information regarding base and certain ancillary rates and the providers in-network status with payors. The Subcommittee declines to adopt GAO’s other recommendations regarding disclosure of air ambulance provider business models.
  • The Subcommittee does not recommend that air ambulance providers distinguish air transport and non-air transport charges on consumer bills or claims to insurance providers or provide cost allocation information related to air transport and non-air transport costs. The Subcommittee finds that such a recommendation would raise practical concerns and generally lead to negative impacts on all stakeholders, while generating only limited benefits for some stakeholders.

Subcommittee on State and DOT Consumer Protection Authorities

This Subcommittee was comprised of consumer groups, DOT representatives, insurance industry representatives, insurance regulators, and transport industry representatives. Their recommendations included:

  • That States adopt preauthorization requirements for non-emergency air ambulance transports to align the patient, the insurer, and the air ambulance provider on the billed charge for the transport. These preauthorization provisions would: (a) require a hospital/doctor to initiate the preauthorization process, arrange transport, and ensure transport is with a provider that is in-network with the patients’ insurer; (b) encourage advance agreement between an insurer and air ambulance provider on price and medical necessity; and (c) obligate the insurer to disclose to the patient the full billed charge of the transport, the amount the insurer with cover and pay, and the amount of the patient’s responsibility broken down by deductible, co-pay and co-insurance amounts.
  • That States establish programs to require or encourage insurers and air ambulance providers to disclose certain key information to the public on a regular schedule. Specifically, these programs would require disclosures by insurers and air ambulance providers of the network composition; incentivize voluntary disclosure by air ambulance providers of their base rates, mileage rate, and any other amounts charged; require disclosure by insurers of the maximum allowable amount for air ambulance services; and require disclosure by insurers of the average amount of balance billing by air ambulance providers. IDR programs are available only to air ambulance providers that voluntarily agree to publish their rates, and States publicize a list of air ambulance providers who refuse to publish their rates voluntarily and publish historical price data for any such air ambulance providers.
  • States create IDR programs to resolve contested air ambulance provider bills as a voluntary alternative to a court determination. The States would make their IDR programs available only to air ambulance providers that voluntarily agree to publish their rates and not balance bill patients. To participate in these IDR programs, insurers must hold the patients harmless from the balance of the charged bill from the air ambulance provider other than the co-payment amount, coinsurance rate, or deductible with respect to such air ambulance services. After an insurer makes an interim initial payment to the air ambulance provider, either party can initiate IDR.
  • Congress appropriate money to DOT to fund the hotline number referenced in section 419 of the FAA Act, and codified at 49 U.S.C.42302.
  • DOT requires air ambulance providers to disclose their rates, and certain billing and insurance network composition information, to consumers.

WHAT DOES ALL THIS MEAN?

The recommendations of each Subcommittee are currently under consideration by the full Committee. There was quite a bit of overlap in the recommendations from various Subcommittees and several themes emerged.

  • Get the patients out of the middle of these disputes.
  • Insurers and Providers must both be more transparent.
  • Insurers and Providers must negotiate, in good faith, to set reasonable economic parameters for the delivery of air ambulance services.

The final recommendations from the Air Ambulance Patient Billing (AAPB) Advisory Committee will eventually be published and are available on the docket (DOT-OST-2018-0206) and can be accessed via the Committee’s website at https://www.transportation.gov/airconsumer/AAPB. This includes the recording of the May 27 and 28 meetings.


*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement and consulting.

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