If Congress truly wants to impact the surprise bill and balance billing issue, let them scrutinize coverage and reimbursement shortfalls by both government-funded and private insurers.
Surprise bills happen because insurance companies don’t want to pay for the cost of service. If there’s no contract in place to entitle the purchaser to a discount percentage off billed charges, then the chips will fall where they may on this.
We spoke with Maria Todd of AskMariaTodd™, an expert with more than 3 decades of contracting between health plans and providers and she laughed when we asked her “What’s in gonna take?” Her response was to regulate minimum coverage around benefits.
“I can remember when a hospital in Henderson, NV, some 18 years ago said, “We’re quitting Anthem because out-of-network, we make more money and get closer to our costs to deliver care. The ambulance and flight for life copters drive them here and deposit them on our doorstep. We don’t stand outside with a hook and snag them as they drive by. They have to pay us because the law says that they are on the hook for emergency care no matter what, in-network or out-of-network. Protocol is to transport to nearest facility. From ED they get admitted for a few days. It costs more to move the patient someplace else than it does to pay is the differential. Why spend money to contract and fight and increase the acrimony. We’ll see them at the cash register on the way out.”
Balance or surprise billing occurs when a patient’s insurance fails to cover the cost of care and holds the patient responsible for paying the balance — an issue that includes emergency room visits, air medical care, hospital stays, medicines and more. It’s like a restaurant. If you order a fancy bottle of wine and desert you will be expected to pay for it when it is time to settle up. It isn’t a surprise.
Transparent, bundled service encounters for surgery, diagnostics, and lab testing are the way to nip balance bills and surprise bills. That requires negotiation.. Cut out the middle man, cut out the fees and commissions and cut the redundancies of having 495 accredited insurance companies administered and licensed in 50 states across 5-6 brands and you’ll cut all those health insurance and HMO C-Suite salaries and benefits, redundant plan administration, banking, NCQA accreditation costs, staffing costs, software licenses costs, and more. all those costs of contracting and provider relations, redundant credentialing and privileging overheads, Poof! Gone!
One plan across all 50 states. One credentialing and privileging application. One claims payment team. One contract, nationwide. One CEO salary. One CFO salary. One Medical Director Salary. One clinical policy guidelines document set. One set of coverage rules. No more disclaimers that state “pre-authorization does not guarantee payment.” Gosh! I hear Louis Armstrong singing What a Wonderful World!
It would cut a bunch of jobs in the industry, but insurer consolidation does that. It culls the best breed and sends the others back for more education or back looking for something else on LinkedIn. We won’t be importing labor from China or Mexico or India. We simply contain costs without cutting care. “One could argue that the system was set up incorrectly to begin with.” says Todd.
What? It’s okay to tell the providers to cut costs as long as the sacred insurance cows are left alone? Hmm. Mooooooooove over! These times are a changin’. Sacred cow burgers are on sale at the local In-N-Out. Get ’em while they’re hot! Order fries and a drink. These are tough old burgers! Oh, and don’t be surprised when they charge you for the fries and the drink.