Out-of-grid emergency payments were twice the baseline

Out-of-grid emergency payments were twice the baseline

In a new study that sheds light on “surprise billing,” researchers found that insurers paid out-of-network reimbursements in emergency medicine that were about double in-network median rates. Self-funded insurers coughed up more money than fully insured insurers, suggesting they were more willing to cut fees paid by insured patients.

Overall, “insurers were allowing much higher out-of-network payments than in-network payments,” said study lead author Erin Lindsey Duffy, PhD, MPH, a Schaeffer Center for Health Policy and Research Fellow. Health from the University of Southern California. Economy, in an interview.

The study was published on September 16 in JAMA Health Forum.

The researchers conducted the study in light of the implementation of the No Surprises Act on January 1, 2022. The law attempts to address the issue of “surprise billing,” which can leave patients with exorbitant medical bills and unexpected when off-grid. health professionals provide care.

As Duffy noted, one element of the law has spawned litigation – the “eligible payment amount” (QPA), a benchmark for reimbursement in the event of a dispute over an invoice. “We wanted to better understand how the amounts authorized by insurers before the law without surprises corresponded to the eligible payment amounts.”

Emergency medicine bills are of particular interest, as previous research “has shown that approximately 1 in 5 emergency care episodes involve an out-of-network health care provider and likely result in a surprise medical bill,” a said Duffy. “Emergency medicine services are inherently more likely to involve out-of-network care because patients generally seek the nearest available care urgently, often transported by ambulance. Patients do not choose their care providers from urgency based on network status or price, which stands in stark contrast to how patients choose a provider for more scheduled or elective services.”

For the study, Duffy and her colleagues analyzed 2019 emergency drug claims data from Aetna, Humana and select Blue Health Intelligence plans. They focused on the median QPA, “which was calculated as the median allowable amount of all observed claims in strata defined by geographic region, CPT code, and funding market.”

Duffy explained, “We didn’t assess the fee – the bill that providers send. We assessed the authorized amounts – the amount the insurer agrees to pay.”

Out of 7.6 million claims, the average claim was $313 and the average QPA was $133. “Among the 650 geographic and market strata in the sample, the average amounts authorized in the network were 14% higher than the estimated QPA,” report the researchers. “For the subset of strata with a sufficient sample of out-of-network claims (n=227), mean out-of-network payments were 112% higher than QPA.”

Self-insured plans were more likely to pay higher out-of-network payments than fully insured plans (2.2 times QPA estimates, versus 1.43 times). “High out-of-network authorized amounts protect patients from surprise medical bills because the magnitude of a surprise bill is the balance between the charge and the authorized amount,” Duffy said. “Large self-insured employers had an interest in protecting their employees from surprise bills, and they were willing to make high out-of-network payments to do so. Fully-insured plans may have lacked the same motivation or will .”

Going forward, under new policies mandated by the No Surprises Act, “insurers may not want to continue their practice of authorizing out-of-network emergency drug payments that far exceed the amounts allowed in-network. “, said Duffy. “This could reduce revenue for urgent care provider groups that used surprise billing as leverage in price negotiations or relied on high out-of-network payments.”

In an interview, Alan Sager, PhD, professor of health law, policy and management at the Boston University School of Public Health, said he was surprised by the finding that self-funded plans paid excessively higher sums.

“Maybe they were more likely to cover out-of-network care,” he said. “Or maybe they are more generous in the share of costs they cover. I would have used the term ‘self-insured’, which means the employer bears the risk of higher claims, not the insurer. I don’t think that’s a great practical distinction for patients, caregivers, or healthcare costs in the U.S. But it’s a distinction that allows large private employers – those large enough to self-insure – to evade mandatory coverage by the state and other regulations.

Overall, he said, “the data and analysis presented for this research speaks to convoluted payment methods and the absence of a fundamental peace treaty between payers and physicians. We must pay doctors well enough and simply enough, that they stop thinking about their fees and their income so often, so emotionally and in so much detail, it will free them to focus on spending money carefully to do as much clinical good as possible.

He said the No Surprises Act is a mess. “The new out-of-network price arbitration rules are a delight for lawyers – complicated, unclear and with lots of opportunity for litigation. They are a recipe for more administrative waste and distrust of health care in the United States. They are not the simple dispute resolution mechanism that supporters apparently had in mind.”

Arnold Ventures funded the study. Sager and Duffy report no relevant financial information. Relevant financial relationships of other authors are listed in the original article.

JAMA Health Forum. Published online September 16, 2022. Full text

Randy Dotinga is a freelance writer and board member of the Association of Health Care Journalists.

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