DOCTORS' LOUNGE
(continued from page 27)
Arbitration applies to amounts exceeding $500 for services rendered
in an emergency department or hospital. The language reads, “In
an effort to settle the claim before mediation, these parties must
participate in an informal settlement teleconference not later than
the 30th day after the date on which a person submits a request for
mediation.” The formal mediation must take place within 180 days
of the request.
Previously, Texas had an arrangement for mediation that not
enough people knew about; as preliminary discussions for this bill
took place, patients took note. The Texas Department of Insurance
received 686 requests for mediation in 2014; in 2018 they received
4,445 requests.
Nationally, in May of this year, the House Ways and Means
Committee heard testimony from the AMA, America’s Health In-
surance Plans (AHIP), and the ERISA Industry Committee (ERIC)
about the severe impact of balance billing not only on individual
patients, but also on efforts to improve patient care and reduce
overall spending. Per its representative Mr. James Gelfand, “ERIC
is the only national association that advocates exclusively for large
employers on health, retirement and compensation public policies at
all levels of government.” This group offered three solutions to help all
parties: patients, their insurers, their employers, their hospitals and
doctors. They recommended three crucial things be part of the law:
» » An in-network matching rate guarantee, in good faith, from
all insurers paying a bill.
» » An emergency last resort benchmark “backstop” for when
negotiations between the payor and the payee bog down; they
recommend negotiating for 125% of what Medicare would pay
for the same service.
» »
The requirement of informed consent: this applies to when a
patient is transferred to a different provider from the original
one; Congress should require the patient to consent if there is
no possible in-network alternative available.
Dr. Bobby Mukkamala, MD, member of the AMA Board of
Trustees, explained that the AMA position is that the national laws
should first of all protect patients. The law should also regulate
any network to include an adequate ratio of physicians to patient
need, including hospital-based physicians, on-call specialists and
subspecialists, taking into account geographic driving distance
standards, and maximum wait times. Regulation should include the
ongoing active evaluation of such networks for adequacy of access to
in-network hospital-based care. Additionally, fair payment to pro-
viders is essential, with provision of a minimum payment standard
at community rates and a binding arbitration process. Finally, for
patients who choose in advance out-of-network procedures or care,
there must be utmost transparency beforehand with clear estimates
of their anticipated costs.
As of July 8 th , the bipartisan U.S. Senate Bill 1895 (the Lower
28
LOUISVILLE MEDICINE
Health Care Costs Act) from Sen. Lamar Alexander et al has been
placed on the Senate Legislative Calendar, having been voted out
of the Committee on Health, Education, Labor and Pensions, over
the dissenting vote from Sen. Rand Paul. The House bill is also
bipartisan, cosponsored by Reps. Frank Pallone and Greg Walden
of the Energy and Commerce Committee. A major point that will
have to be worked out in the conference committee is how much
the insurer must pay for out-of-network bills received.
However, none of the national bills address ambulance billing.
In particular, air ambulances are independent contractors and they
negotiate costs separately; they serve rural areas where speedy trans-
port can save lives. They also can cost $15,000 to $75,000. I have long
heard horror stories from my patients about the $900 “discharge”
ambulance ride from the hospital to the nursing home. At this point,
no one knows if amendments will be made regarding this issue.
I’m grateful that there appears to be some groundswell of sup-
port in Congress and in multiple states, separately, for protecting
our patients (and ourselves) from the enormous cost of accidents
and medical emergencies. ER doctors are going to take care of you
regardless, but the hospitals that supply the services cannot go broke
and render that care impossible. We need Congress to act. If you are
looking for a way to advocate for your patients, for something to call/
meet with your Representative about, have I got a deal for you!
Dr. Barry practices internal medicine with Norton Community Medical Associates-Bar-
ret. She is a clinical associate professor at the University of Louisville School of
Medicine, Department of Medicine.
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