The No Surprises Act is a revolution to health care consumers.
Watch this excerpt from our webinar where we discuss the importance and impact of the No Surprises Act.
Video Transcript:
Bruce Gillis:
Hi, this is Bruce Gillis, and welcome back to another edition of Brews with Bruce. Today we're going to be basically replaying an excerpt from a webinar that was hosted on January 7th, that reviewed the recent appropriations bill and COVID relief bill that had various implications to group health plans. Specifically, the segment that we're going to talk about is the No Surprises Act. The webinar from January 7th is available online at Businessolver if you want to see the whole thing, and featured Josh Holman from Businessolver, Ben Conley from Seyfarth Shaw, and myself talking about the various aspects of the appropriations bill.
Bruce Gillis:
This particular segment is speaking to the No Surprises Act, which in coordination with the Transparency Rule that was issued earlier last year, provides a lot of powerful information to employees and group health plan participants in terms of making decisions about the cost of their health care. Without further ado, we will join the excerpt which we'll feature Ben Conley from Seyfarth Shaw regarding the No Surprises Act.
Josh Holman:
All right, No Surprises Act. Here's a little stat we picked up on a white paper called The Case for Personalized Employee Benefits Experience. We will post this in the chat, so take a look at it if you want to delve into some details. But get this, in a 2019 survey, we found that across all Americans almost 50%, 44% of Americans have received a surprise out-of-network bill. Of those that had, almost 70% said the bill was difficult to pay, and 11% said they could not pay the bill at all. This is a lot of people. This is a big impact. Check the chat for a dive into that bill, and I'm stealing your thunder here as we dive into the No Surprises Act here Ben, so let me tee you up. What are your thoughts? Where do things stand on the No Surprises Act?
Ben Conley:
Yeah. Thanks Josh, and your first question might be, were we surprised to see the No Surprises Act included in the year-end legislation. Perhaps unsurprisingly, we were not surprised. This has been a bill that has been batted around in Congress for two or three years now taking on various iterations. It's been a high-priority issue, a bipartisan issue, and it is intended to address three specific scenarios where participants are often adversely impacted through what in Congress's eyes is no fault of their own.
Ben Conley:
The first is a situation in which an individual has an emergency medical condition. They end up in an out-of-network hospital, and because it's out-of-network end up with a big balance bill. The second is the situation where the participant does everything they're supposed to. They find their network hospital, they go in for a procedure, they're put under by an anesthesiologist, and then five different doctors come in and do things to them, good things, right, medical procedures, and one of those doctors happen to be non-network. Right? Person was unconscious. There's nothing they could have done about it, and they get hit with a balance bill.
Ben Conley:
The third is the controversial topic of air ambulance services which are notoriously unwilling to negotiate with TPAs to be in their network, and so quite often are non-network. Obviously when air ambulance is used, it's a circumstance where participants have usually little say in the matter. Right? So the thought in Congress's eyes is, look we don't know who should be responsible for these bills, but it really shouldn't be participants in that context, so we're going to look at the two entities with the deeper pockets here. That is the providers and the payers, that being the insurance carriers or the employer plan sponsors who pay the bills for self-funded plans, and require them to meet somewhere in the middle to ensure that there is no balance billing to participants. That's the context.
Ben Conley:
If we can go to the next slide that led to the No Surprises Act being included in this legislation. So the gist here is that there are mechanisms put in place that will go into effect generally in 2022, that will ensure that in those three scenarios that we discussed, participants won't have balance billing. Right? They may have cost sharing or other obligations, but they won't have these massive balance bills. You know, the circumstance where the provider charges $20,000, the plan says, "Well, we think the service is worth 500," and the participant's left paying the difference.
Ben Conley:
Just highlighting a few quick provisions included in this legislation. Generally speaking, they borrowed a concept from the ACA's earlier provisions relating to emergency medical services requiring that in those three scenarios cost sharing be calculated at the same manner for those out-of-network services as they would be for in-network with the repricing being done at the median in-network payment amount. Again, borrowing from the ACA to a certain extent. When those bills come in in those three settings, the plan must either pay that bill or object within 30 days. And the timeliness there is contingent and important for purposes of facilitating the rest of the process.
Ben Conley:
Then just the final one I want to highlight here, and this was the big sticking point in Congress. The concept was, look we know that the provider charge might've been too high, but we know that what the plan pays, which is often the Medicaid, Medicare rates, which are Congressionally set, right, are probably too low. So what do we find as a middle ground here for the appropriate payment amount? What they settled on here was, let's throw out those two extremes and instead have the government gather data and find out an appropriate median rate based on regular rates of payment in that region for that type of service, and require the parties to come to the table and arbitrate to meet somewhere around that figure.
Ben Conley:
Once that figure is determined, that's what the plan has to pay. That's what the provider has to accept, and there can be no balance billing to the participant. So that's the secret sauce here is that if everything goes according to schedule, providers are probably not happy because they're getting a little less than they think they should have, plans are probably not happy because they're paying more than they would have had to under prior regimes, but at least there is no balance billing to participants. So stay tuned on this one. There's regulations expected in the next couple months that will flesh out the details on how this all looks. But generally speaking, this is going to change the game with respect to out-of-network services.
Josh Holman:
Yes. In fact, that's a good segue to ask our audience a question about out-of-network services. On the next slide you'll see another poll with radio buttons. Question being, "Do your members struggle to understand network versus out-of-network care," from all the time, to rarely, and never. Give you some time to see how you vote, but Ben, what are you guessing on the outcome of this survey?
Ben Conley:
Yeah. I mean it's hard to stay sort of in the traditional mindset because a lot of folks on the webinar today do this stuff day in and day out, so this becomes more second nature. But health insurance is really complicated. Right? Without a doubt, and I have to remind myself when I'm going to the doctor, "Hey. Here are the important things I need to think about. Is this a network doctor? What's my cost sharing obligation going to be? Where am I with respect to my deductible to predict how I might have to pay for this service?" So yeah, I think participants don't understand this, and I think that's what's being reflected here as well.
Josh Holman:
You got it, and you nailed it. You're looking at 65% of members struggling to understand. I know I've been in that boat. You know, you get that one line item on there that you just weren't prepared for, so that makes sense to me. Okay.
Ben Conley:
By the way, I saw a question come through that was, does this No Surprises Act only apply to ERISA groups, and the answer is no. This applies to all group health plans. They took a framework similar to the ACA and required that this apply, public sector, individual insurance plans, and group health plans.
Josh Holman:
Great. Okay. Thank you, Ben.
Bruce Gillis:
That was Josh Holman and Ben Conley speaking to the No Surprises Act. Again, I look at that and I think that the removal of surprise billing to the individual participants in conjunction with the transparency rule that recently went into effect that will require plans to publish the cost to the participant or the plan participant of certain medical procedures, gives the participants the opportunity to have a lot of transparency and accuracy in knowing how much things are going to cost. It's a great opportunity for employers to communicate, to create a more informed health care consumer, and so there's opportunity there.
Bruce Gillis:
There's some work, especially around the transparency rule. The No Surprises Act is going to require some changes on the payer side and on the provider side. Those changes are going to be largely invisible to the participant other than the fact that they won't see surprise bills. But I do think there's an opportunity here for health plans to work to create a more informed consumer.
Brews with Bruce is live every other Friday at 4pm EST. Check our event page for latest date here.
For more blogs sent directly to your inbox, subscribe below.
