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Regulate Network Adequacy to Stop Surprise Medical Bills

Regulate Network Adequacy to Stop Surprise Medical Bills

Wednesday, May 22, 2019

Policies aimed at addressing unanticipated out-of-network care—often called surprise billing—should not put patients in the middle of payment negotiations or reward payers whose inadequate, narrow provider networks are a primary driver of the problem.

That was the key message from MSMS President-elect and American Medical Association (AMA) Trustee S. Bobby Mukkamala, MD, at Tuesday’s House Ways and Means Health Subcommittee hearing on surprise medical bills.

“The AMA has long been concerned about gaps in out-of-network coverage and is committed to working on solutions to protect patients from the financial impact of ‘surprise’ coverage gaps,” said Doctor Mukkamala, a board-certified otolaryngologist—head-and-neck surgeon who practices in Flint.

Congressional action on the issue should protect patients, ensure that payer provider networks are adequate, establish fair payment for physicians, and increase transparency, Doctor Mukkamala said.

Doctors want to be included in health-plan networks, but they want to do so on the basis of fair contracts, he added. Most health insurance markets are highly concentrated, and 57% of physicians work in practices of 10 or fewer physicians. Those factors combine to leave physicians in a weak negotiating position with large commercial health insurers, Doctor Mukkamala said.

Network adequacy requirements are a key part of the successful approach to surprise billing in New York state. The Empire State’s legislation has led to a dramatic fall in consumer complaints, according to a report—“New York’s 2014 Law to Protect Consumers from Surprise Out-of-Network Bills Mostly Working as Intended: Results of a Case Study”—issued by Georgetown University’s Center on Health Insurance Reforms.

Bring insurers to the bargaining table

Doctor Mukkamala urged Congress to avoid purported fixes that set minimum pay benchmarks based on Medicare rates or payers’ in-network rates.

The in-network rates “are negotiated by physicians and plans during the contracting process and fees are discounted in exchange for contracted benefits,” Doctor Mukkamala told the committee. “Those companies that didn’t sit down to negotiate should not benefit from skipping that step.”

Using discounted rates for out-of-network care would likely lead health plans to “quickly drop physicians from their networks knowing they could use our services for less when we are outside their network,” he added.

Pay benchmarks should be based on data from independent sources, Doctor Mukkamala said. In the past, flawed and conflicted insurer-controll