FAIR Health Presents on Balance Billing at ACHE

March 18, 2021

Next week, FAIR Health President Robin Gelburd will virtually present to the American College of Healthcare Executives (ACHE) Congress on Healthcare Leadership. From March 22 through March 25, conference attendees can view Ms. Gelburd’s on-demand session, entitled “Balance Billing: The Implications for Healthcare Executives of Current Legislation, Policy and Regulation.”

Drawing from FAIR Health’s experience supporting state and federal surprise billing solutions, Ms. Gelburd’s presentation will examine the latest laws, policies and regulations concerning out-of-network emergency and surprise bills that may affect healthcare executives in their areas of operation.

Surprise Billing Laws and Legislative Activity at State and Federal Levels
Ms. Gelburd will explore proposed and enacted legislation concerning surprise billing and evaluate the different models used to resolve payment issues among providers and payors. Several state statutes considered in the presentation incorporate FAIR Health’s cost benchmarks as guidelines or standards for payments and dispute resolution. These states include New York, Connecticut, New Mexico, Texas and Georgia.

Connecticut’s surprise billing law, for example, provides that out-of-network professional emergency and lab services are to be reimbursed at the highest of three categories: the in-network amount for the service; the usual, customary and reasonable rate (UCR) for the service; or the Medicare rate for the service. Connecticut’s Commissioner of Insurance designated FAIR Health’s 80th percentile of billed charges as the approved data source for UCR.

Data Implications of Surprise Billing Models
Ms. Gelburd also will provide concrete examples from FAIR Health’s data repository that show the implications of different state approaches to resolving the issue of compensation for out-of-network care.

Texas’s surprise billing statute, for example, considers both the 80th percentile of billed charges and the 50th percentile of estimated allowed amounts when determining reimbursement in arbitration proceedings. In Ms. Gelburd’s presentation, FAIR Health data will reveal how these values vary throughout Texas for CPT^®1 12001, repair of a wound of the scalp, neck, underarms, genitalia, trunk, arms and/or legs (2.5 cm or less)—a common emergency room procedure. Statewide, the 80th percentile of billed charges is $580, while the 50th percentile of estimated allowed amounts is $161.

Healthcare Executives’ Role
After reviewing the varied statutory approaches to surprise billing and their implications for reimbursement, Ms. Gelburd will discuss how healthcare executives can play a constructive role in furthering the protection of consumers from surprise billing.

For example, Ms. Gelburd will suggest that healthcare executives support surprise billing protection by establishing clarity in the marketplace through transparency efforts. This might include developing consumer-friendly educational resources to advance health insurance literacy or offering easily accessible cost information in order to establish trust with patients.

^{1 CPT © 2020 American Medical Association (AMA). All rights reserved.}