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By law, payers set prices based on regional averages for networked providers on the specific billing code, or services rendered. Insurers must pay non-participating providers the highest reimbursement of the regional median price of 150% of the Medicare rate.
DIFS is responsible for reviewing a carrier’s calculation of its median negotiated amount at the request of a non-participating supplier. Each year, it must prepare an annual report.
“We see this as an opportunity, first and foremost, to take the patient out of the middle of the process and allow them to be between business entities, a supplier and an insurer, and not the unsuspecting patient policyholder,” he said. Fox said.
DIFS has yet to receive a call from a non-participating provider wishing to disagree on the median price set by health insurers, Fox said, adding that arbitration can only be used for claims from emergency.
Fox gave the unusual example of a patient presenting for a routine delivery and the provider finding out that the babies are Siamese twins. If the insurer rejects the claim for the more complicated procedure, the non-participating supplier may request arbitration to receive additional reimbursement.
Patients on employer-sponsored plans under ERISA, or the Employee Retirement Income Security Act 1974, will also soon have some protections against balanced medical billing at the federal level.
In December 2020, Congress enacted the No Surprises Act that prohibits off-grid providers who administer emergency services from charging a patient more than the applicable network cost. All surprise medical bills must be covered by insurers at network rates.
As of January 1, non-participating healthcare providers also cannot charge patients more than the network cost for these services.
Fox said the federal bill will supplement Michigan law once the regulations are in effect.
Pallone said he expects legal challenges from some non-participating providers, but over time state law will generate benefits for patients and insurers.
“What worries me is that the bill did not respond to (surprise bills) for air ambulances. It is a national problem. Air ambulances say the law does not apply to them. “said Pallone. “” Our hope is that state law will apply. We may need some follow-up (laws) on this. “
Pallone said he hopes the law will reduce problems for patients, lower overall medical costs and reduce administrative burdens for payers.
“The greatest value is for the consumer. They are our clients. If they are not satisfied, they turn to us as well as to the supplier. Pallone said. “Our hope, downstream, is administrative efficiency and a decrease in the number of appeals with arbitration.”
Rivet said he believed the law would benefit patients “who are struggling with sky-high bills.” However, patients must accept the responsibility of carefully reviewing all medical bills.
“If you get mail from an insurance provider, you need to open it and read it. Don’t assume the provider is off-grid, it’s okay. If you have a balance that doesn’t seem right, challenge it. the, as you do charge on an American Express invoice. “
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