Surprise Billing Debate Continues to Transfix State and Federal Policy Makers
FAIR Health Experience and Data Inform New Look at Prominent Healthcare Issue
NEW YORK, NY—March 6, 2019—FAIR Health today released a brief intended to increase clarity about the implications of various legislative choices related to surprise billing—a subject of intense debate on the state and federal level. Entitled Teasing Apart the Threads to the Surprise Billing Debate: Understanding Policy Choices through the Lens of Independent Data, the brief is based on FAIR Health’s experience consulting with policy makers and stakeholders on the issue and on data from its repository of private healthcare claims, the nation’s largest. FAIR Health is a national, independent, nonprofit organization dedicated to bringing transparency to healthcare costs and health insurance information.
Surprise or balance billing occurs when consumers receive bills, often substantial, 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. In its new brief, FAIR Health 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 brief discusses the option of mandating a value for reimbursement based on a clear benchmark, and details the four types of benchmark generally proposed: • a percentile value based on the range of providers’ charges (nondiscounted fees) for a service in the relevant market; • a formulation based on allowed amounts, which are the in-network fees paid under a plan to a provider for a service; • a “hybrid” blend of benchmarks for billed charges and allowed amounts; or • Medicare fee schedule rates or a multiple thereof.
Also discussed is the principal alternative to a mandate, independent dispute resolution (IDR), whether with or without articulated guidelines for reimbursement. The brief also considers the value of making reference to an independent, objective database in designing legislative solutions.
Data visualizations in the brief illustrate the implications of the varying approaches under consideration by federal and state policy makers. The visualizations compare different types of value, such as median charges and median allowed as well as Medicare fees, for different medical procedure codes in different states and local areas.
FAIR Health President Robin Gelburd stated: “Surprise bills are a pressing legislative issue across the country. The implications of various approaches to the issue are complex. We are pleased to use real-world data, reflecting actual healthcare economics in local markets, to help tease apart those implications.”
For the full brief, click here.
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