Urge your Insurance Commissioner to Protect Patients' Access to Healthcare!
Recently, several large, national commercial medical insurance plans, have employed aggressive tactics against contracted physicians that only benefit commercial plans. Most carriers have reported record profits during this pandemic, yet they are still compelled to take advantage of misguided legislation and flawed Medicare payment policies.
Surprise Medical Billing (SMB) and Out of Network (OON) state laws were passed in an effort to remove the patients from receiving a bill. However, in states whose SMB/OON laws do not adequately protect physicians negotiating rights, we see several carriers taking advantage of the OON legislation and terminating contracts with network providers at an alarming rate. Federal legislation has also been proposed, which would require that health plans reimburse OON physicians at an “in network median rate” which is known only by these plans.
- They are doing so to groups that are currently contracted at rates higher than what the statutory levels set by these recently passed laws. Those statutory levels are often set at the “median in network” rates and require that the health plans initially reimburse physicians at this median in network rate. Since the median rates are usually known only to the health plans if such rates are not tethered to an independent data base, the health plans have been terminating any physician participation agreements that are in excess of these rates to manage the median downward in anticipation of the federal and/or state OON laws.
- All physician groups rely on commercial rates to offset the lower rates paid by governmental payers and self-pay.
The result will be to decrease physician reimbursement at a time when they are stretched thin in fighting the pandemic and rebounding from cancelled elective and screening procedures. Many hospital based physician groups saw volume decreases of 40-50% in March and April and many continue to experience volume declines of -20% today—and are expecting to see the same in the first half of 2021.
We are also seeing certain carriers adopting the new valuation of E/M codes beginning in November of 2020. As you know, CMS is proposing to change these values to compensate E/M codes at a higher level, and budget neutrality requires that other CPT codes suffer beginning in 2021.
- CMS is proposing this by reducing the conversion factor by 10.6%. While we are supportive of the increases for E/M codes – we also know that many specialties will face significant payment reductions — hospital based specialties and their care teams who are the front line physicians in response to COVID-19.
- CMS and federal lawmakers are also aware and scrambling to find a fix or a delay to make sure these cuts are avoided.
The result is that unilateral changes to carriers’ contracts will lead to physician shortages (especially in rural areas) at a time when these services are desperately needed.
We are at a critical point where access to patient care will become a real issue for every state in the country. Tell your state's Insurance Commissioner to resolve these growing issues by putting these greedy giants on NOTICE!