Insurance Claims: How to Handle Medical Billing Disputes
Billing errors on a medical bill can be a serious headache to rectify. Here’s how to do it to clarify things.
Nearly one in five hospital visits leaves patients with the unpleasant surprise of a surprisingly high bill because doctors or other providers were not part of their insurer’s network.
To protect consumers, Congress passed the bipartisan No Surprises Act last December. But doctors and hospital groups are trying to delay its deployment on January 1 on a narrow but crucial portion which, according to them, unfairly favors insurers.
On Thursday, the American Medical Association, American Hospital Association, and hospitals and physicians sued the federal government to suspend arbitration rules proposed by federal regulators, which would effectively end the most common forms of surprise billing.
The proposed rule unveiled by the Department of Health and Human Services and other federal agencies would give providers and insurers 30 days to resolve disagreements over payments or submit to binding arbitration to settle disputes. The lawsuit said regulators had misinterpreted the law and proposed an “unfair and illegal” arbitration system that begins with benchmarks already negotiated by health insurers – the network median rate for similar medical services.
The lawsuit argues that insurers will rely on the arbitration rules to get an “unfairly low rate” and have little incentive to include higher-cost providers in their network, “at the expense of patients.”
“Our legal challenge urges regulators to ensure that there is a fair and meaningful process to resolve disputes between healthcare providers and insurance companies,” said WADA President Gerald E Harmon.
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The lawsuit follows a wave of public comments submitted before this week’s deadline by supporters and detractors of the proposed rules.
Also this week, a Nevada jury ruled that UnitedHealthcare must pay subsidiaries of emergency medicine staffing company TeamHealth $ 60 million in damages for the insurer’s payment practices.
CEO Leif Murphy said the jury’s decision “helped stop the bleeding amid a pandemic” for TeamHealth, which provides doctors for 12% of emergency rooms in hospitals nationwide.
Murphy said his company filed several lawsuits against insurers across the country over payment disputes before Congress passed the surprise billing legislation. He said the cost of staffing doctors to take care of patients when they are in emergency rooms or admitted to hospitals is becoming increasingly difficult to cover due to attempts by insurers to cut reimbursements. He fears that the new federal law will “shift the balance of power” to the big insurers and encourage them to terminate more expensive contracts to reduce the median price of services – which is the proposed starting point for arbitrage.
“We are facing extremely high stress levels, a lot of uncertainties on the front line, anticipation of a COVID outbreak at any time,” Murphy said. “And then you say we’re not going to recognize the value of the service provided and are you going to cut wages? That’s not a good situation.
A spokesperson for UnitedHealthcare said the insurer would appeal the Nevada case “to protect our clients and members from privately funded physician endowments that charge exorbitant and anti-competitive rates for their services. and increase the cost of care for everyone “.
“No one should have to worry about going bankrupt”
In November, an HHS report found that 18% of emergency room visits by Americans with employer-sponsored health insurance resulted in out-of-network charges. Patients who underwent operations or gave birth at network hospitals had similar out-of-network expense rates.
According to the report, these unexpected fees have averaged over $ 1,200 for anesthesiologists and $ 2,600 for surgical assistants.
“No one should have to worry about bankruptcy after falling ill or seeking intensive care,” HHS Secretary Xavier Becerra said of the report.
Federal legislation has won broad support among consumers, employers and insurers looking to slow the rising cost of health care.
America’s Health Insurance Plans, the trade association for private insurers, said millions of consumers face financial hardship every year after receiving medical bills from off-grid providers.
The Biden administration’s rules for implementing the law “are a critical step in ensuring that … surprise medical bills are a relic of our past,” the trade association said in a statement.
The Congressional Budget Office estimated that cost savings from lower medical bills would reduce private insurance premiums by 0.5 to 1% and reduce federal deficits through savings from employer plans and affordable health care plans. subsidized by taxpayers.
“Surprise billing has been a problem for decades,” said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. “It has become more of a problem and more pronounced over the past decade.”
The problem worsened, Adler said, as private equity firms acquired medical specialties such as anesthesiologists or emergency medicine staffing companies.
Hospitals often need to be covered by these specialists, whether or not they sign contracts with large private insurers. In cases where these specialists refuse to sign a contract with insurers, they set their rates themselves. In some cases, consumers are billed for balances that the insurer does not cover.
Even if consumers take the extra step of verifying that a hospital or other medical facility is a network provider for their insurance plan, they often have no control over whether physicians and other providers networked hospitals are part of their insurer’s network.
“The balance of negotiations has been tilted in favor of physicians in this subset of specialties like emergency medicine and anesthesiology,” Adler said.
Others say federal law will provide patients with long-awaited protections.
“We have seen firsthand the devastating financial and emotional impact that happens to patients when they receive surprise medical bills,” said Nancy Brown, CEO of the American Heart Association.
Brown said consumers are particularly vulnerable to such excess billing during emergencies.
“They are having a heart attack. They have a stroke. They have sudden cardiac arrest, ”Brown said. “At a time like this (when) there is often no one around you, and if there is, the first thing that comes to people’s minds is not to say to themselves, ‘ Are all of these providers part of this patient’s health insurance network?
But critics of the arbitration rules say insurers will gain the upper hand and force doctors to agree to lower rates. The American Society of Anesthesiologists has said the rules are a “powerful mechanism for large health insurance companies to avoid negotiating contracts and, ultimately, to gain financial concessions from the practices of physicians in the local community “.
The American Medical Association lawsuit said an insurer in North Carolina had previously sent letters to some doctors demanding payment cuts, citing the new federal rules. If those doctors don’t lower their rates, the insurer will end their contracts and leave patients with fewer options, the lawsuit says.
Recruiting companies like TeamHealth believe insurers will only speed up contract terminations if the arbitration rules go into effect on January 1.
“The result of this shifts the balance and begins to threaten our ability to recruit staff,” Murphy said.
Ken Alltucker is on Twitter at @kalltucker, or can be emailed to [email protected]