No Surprise Billing?

Posted On: April 8, 2021 | By: Axion RMS

A new analysis from PwC’s Health Research Institute (HRI) finds that recent federal health care transparency initiatives could have a significant impact on health care consumers, providers, and payers.

What were the two regulatory changes?

  • Transparency:
    • Requires hospitals to publicly post standard charges for all terms and services, which includes the total bill without discounts , any discounted prices charged to self-paying individuals, and minimum and maximum charges for all services and products.
    • Also, by 2023, negotiated costs by providers will be made public, including: rates, billed charges for Out-of-Network providers, and information on Rx
  • No Surprises Act: the new law limits the practice (ground ambulance services exempted), and requires patience to pay in-network prices for any out-of-network bills, with the payer and provider to negotiate a settlement of remaining costs.

Mixed Feelings?

  • The objective was to allow participants and employer groups to easily assess the value of specific services. Yet, most providers are struggling to report pricing information – especially information that can be compared across multiple provider systems.
  • Carriers and providers are arguing this will muddy the waters, making it too complex for small businesses and patients to navigate.

What does this mean for employers?

  • One thing is for curtain, the no-surprise act will provide parity among rates between major carriers, specifically those who operate state by state. Plus, I know there are a lot of patients out there that the “balance bill” is working towards extinction. Yet, organizations, specifically self-funded groups, must prepare to intercede in arbitration between the patient, carrier and provider.  
  • Transparency will improve competition, thus driving overall costs down. Providers, for many years, have had the upper hand because they have the power to set their own prices.
    • As an analogy, think about two gas stations (while a much less complex business) that are across the corner from one another – typically their prices remain generally the same due to common traffic.
    • There will be a challenge at first to compare prices, but over the long-term, this challenge will lesson.

As an employer group, you should monitor the status and effects of these changes as they will greatly impact you and your employees.

Contact Jake Doman at JakeDoman@Axionrms.com to learn more.