Teasing apart the threads to the surprise billing debate: understanding policy choices through the lens of independent data

Teasing apart the threads to the surprise billing debate: understanding policy choices through the lens of independent data

Collection:
Health Policy and Services Research
Series Title(s):
Brief (FAIR Health, Inc.)
Contributor(s):
FAIR Health, Inc., issuing body.
Publication:
New York, NY : FAIR Health, Inc., March 2019
Language(s):
English
Format:
Text
Subject(s):
Accounts Payable and Receivable
Fees and Charges -- statistics & numerical data
Health Care Costs
Insurance, Health, Reimbursement -- standards
United States
Genre(s):
Technical Report
Abstract:
With almost all stakeholders in agreement on protecting consumers from surprise or balance bills that exceed their in-network responsibility, this brief focuses on the current debate on how to determine the amounts that plans should pay to compensate providers. Based on our experience consulting with policy makers and stakeholders and on data from our repository of private healthcare claims, FAIR Health outlines the varying approaches under consideration by federal and state policy makers and includes data visualizations that help reveal the implications of those approaches. One option often considered by legislators and regulators is to mandate a value for reimbursement based on a clear benchmark. Generally, four types of benchmark have been proposed: a percentile value based on the range of providers' charges (nondiscounted fees) for a service in the relevant market; a formulation based on allowed amounts, which are the in-network fees paid under a plan to a provider for a service; a "hybrid" blend of benchmarks for billed charges and allowed amounts; or Medicare fee schedule rates or a multiple thereof. The principal alternative to a mandate is independent dispute resolution (IDR). IDR either may occur in the context of articulated guidelines for reimbursement, or it may have no specific guidepost for reimbursement. The most efficient method for evaluating the implications of the various reimbursement models under consideration is reference to an independent, objective database. Such data provide several advantages, including access of all parties to the same information; protecting payors' proprietary information relating to in-network rates; avoidance of potential provider distrust of payors' reports of their rates and payors' distrust of providers' reports of their fees, and elimination of any need for audit/investigation of payors' and providers' practices.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
Extent:
1 online resource (1 PDF file (20 pages))
Illustrations:
Illustrations
NLM Unique ID:
101751634 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101751634