FAIR Health Serves as a Resource on Surprise Billing

FAIR Health is frequently consulted as a resource on surprise billing by state and federal officials and healthcare stakeholders. In our capacity as a neutral, independent authority on the issue, we recently released a brief to serve as a guide to the debate.

Surprise or balance billing occurs when consumers receive bills for out-of-network emergency care or services they unexpectedly or unintentionally received from an out-of-network provider. Almost all stakeholders agree on protecting consumers from surprise bills that exceed their in-network responsibility, but there is considerable legislative debate on how to determine the amounts that plans should pay to compensate providers.

Surprise Billing Discussions

Over the past four years, FAIR Health has been invited to discuss these issues with legislators, agency heads and governors’ and commissioners’ offices in more than 20 states as well as with federal executive branch officials and members of Congress—all seeking to protect consumers from surprise bills while treating fairly the economic interests of insurers and providers. Possessing the nation’s largest repository of private healthcare claims, we have brought to these discussions our data resources and technical expertise and have acquired a deep understanding of the nuanced issues faced by legislators and stakeholders alike. Our role has included giving oral and written testimony and data cuts to help policy makers and stakeholders understand the consequences of different models.

The legislative discussions across the country have resulted in the introduction of a variety of potential reimbursement formulations—from percentiles of billed charges, to formulations based on allowed amounts (i.e., negotiated in-network rates), to a hybrid averaging both billed and allowed values, to a multiple of Medicare—or the elimination of a mandated benchmark in favor of an independent dispute resolution process (IDR). If IDR is selected, the question arises whether there should be a guideline for consideration in resolving the dispute (such as in the New York law, which uses FAIR Health’s 80th percentile of billed charges as a backdrop to discussions, among other factors) or arbitration or mediation without any articulated standard.

Brief on Surprise Billing

FAIR Health’s new brief, Teasing Apart the Threads to the Surprise Billing Debate: Understanding Policy Choices through the Lens of Independent Data, outlines the varying approaches under consideration by federal and state policy makers and includes data visualizations that help reveal the implications of those approaches. The visualizations compare different types of values, such as a range of percentile values for charges and median allowed amounts as well as Medicare fees, for specific medical procedures identified by official codes in different states and local areas.

FAIR Health President Robin Gelburd stated: “FAIR Health has been at the center of state and federal conversations to protect consumers against surprise billing. By releasing a brief that outlines key considerations associated with surprise bill legislation, we hope to continue our role of using real-world data to help tease apart the implications of the various legislative choices.”

For more information on FAIR Health services to states and the federal government, contact us by email at info@fairhealth.org or call us at 855-301-3247, Monday through Friday, 9 am to 6 pm ET.