“Surprise Billing” Need not be So Surprising: Mitigating the Cost Impact of Out-of-Network Billing
This blog is a deep dive into some of the key considerations in terms of standardizing out of network payment models to streamline processes and benefit multiple healthcare consumers.
Surprise billing has been a long-standing battle between out-of-network providers and Payers. A slew of changes has been implemented including the value-based payment models and other regulatory changes to resolve payment disputes and support Physicians and Patients alike. Despite the constant regulations being rolled out in support of the out-of-network Physicians, policymakers are constantly innovating brand-new strategies to facilitate quick and fair resolution of payment conflicts between the stakeholders. This blog is a deep dive into some of the key considerations in terms of standardizing out of network payment models to streamline processes and benefit multiple healthcare consumers.
Policymakers across the U.S have devised these key approaches to determine the out-of-network reimbursement rates.
To standardize out-of-network payment processes and to make quick and fair reimbursements, policymakers need to consider these key factors.
Predetermined fee schedule
For instance, Oregon regulators set a fee schedule depending on data from the state’s all-payer claims database with adjustments depending on key factors including geographic region and complexity of the issue.
Common benchmarking
For instance, the Colorado state insists that Payers reimburse the greater of two or three possible payment amounts, amongst which one of them is tied to the in-network costs. This applies to the same service in the same geographic area for the prior year based on commercial claims data.
Insurer’s internal data
For instance, consider the fact that in Maryland, there are certain plans that may be required to reimburse certain out-of-network providers at a whopping 140% of the insurer’s average rate paid in the previous year for the same covered service in the same geographic region.
Healthcare leaders involved in payment policies are grappling with new and emerging challenges in resolving payment disputes and making fair reimbursements.Furthermore, the constantly changing regulations and state laws are having downstream effects on out-of-network billing and reimbursement standards. To rise above the challenges, Policymakers need to simplify out-of-network billing by staying committed to innovating sustainable strategies and solutions that meet the evolving needs of healthcare consumers.
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