Insurers are winning the No Surprises Act
Top of the Week
Health insurers are not tired of winning.
The No Surprises Act legislation attempted to create a fair system to arbitrate between clinician practices and insurers when payment rates are not been pre-negotiated for privately insured patients (out-of-network billing). Patients were “taken out of the middle”. However, implementation has benefited insurers at the expense of clinicians.
ACEP and the ED Practice Management Association (EDPMA) have sent this strongly worded letter arguing for improvements in the law’s implementation to the US Department of Health & Human Services, the Department of Labor, and the Treasury Department.
The letter details many ways the independent dispute resolution (IDR) process benefits insurers. The main themes disadvantaging physicians are information asymmetry and delay.
Arbitrators are instructed to include the Qualified Payment Amount (defined as “median contracted rate on January 31, 2019 for the same or similar item or service, increased for inflation”) when determining the appropriate price of a disputed service. Insurers calculate the median contracted rate, setting up a clear conflict of interest.
Not surprisingly, insurers are deflating the QPA. Per ACEP’s letter, “This combination of the QPA methodology and the miscalculations has led to QPAs that ‘don’t even pass the laugh test’—those that are so low that they are even significantly below Medicare and Medicaid payment rates.”
Delays benefit health insurers as well. Any payment not sent to clinicians is money that stays with the insurer. ACEP’s list of insurer delays includes “missing health plan information, failure of health plans to engage or even acknowledge receipt of Open Negotiation initiation, failure of insurers to pay arbitration fees so IDRE does not release the judgment, and health plans failing to pay providers within 30 days post-IDR as required by law.”
EM Practice
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Timely article about restrictive covenants in emergency medicine contracts. (Reminder: The FTC’s comment period for the proposed non-compete ban is still open. Click here to add your comments.)
Yet another article about overwhelmed ERs (this one is about Sparrow Hospital in Michigan). Intro sentence: “Too many patients and not enough staff to care for them.”
House of Medicine
Optum Health (part of UnitedHealth, the insurance company) is the US’ largest employer of physicians.
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Medscape’s survey shows that physicians are less happy than prior to the pandemic.
AI, including ChatGPT, can pass the USMLE exams.
AAMC’s Physician Specialty Data Report. (Data galore!)
Hospitals & Health Systems
Congress’ $1.7T spending bill passed in December 2022 included lots of healthcare programs.
Cleveland Clinic anticipates a $200m operating loss for 2022.
How the lack of competition in the hospital market harms patients.
Nursing & Allied Health
A Qualtrics survey showed that healthcare ranked last for employee satisfaction among 28 industries.
The Dispo
Check out this very cool nonprofit: Musicians On Call, which has brought live in-person and virtual performances to more than 1 million patients’ bedsides. "The amazing part about it is that within a song—just a few minutes—the entire energy of the room is transformed."