One of the first things you likely ask in deciding where to seek medical treatment is whether the doctor and hospital is in your health plan’s network, so you can get the quality care you need at the most affordable price. Yet, even when you’ve carefully selected a medical facility that is in your network, you may still end up receiving some care from a doctor who isn’t.
The result is an unexpected medical bill that can amount to hundreds – or even thousands – of dollars. These costs aren’t only frustrating, they can be financially crippling.
Blue Cross and Blue Shield of Nebraska believes that when patients have done all they can to stay within their medical network, they deserve protection from unanticipated or surprise medical bills. In fact, just about everyone involved in health care – doctors, hospitals and lawmakers alike – says they want to protect consumers.
Yet, as Congress considers how best to achieve this, two different ways to resolve payment disputes involving surprise bills are under consideration. Only one of them would truly protect patients without raising costs for everyone.
Benchmark based rates will save $25 billion
The fairest, most transparent and predictable way to settle payments to out-of-network clinicians is through a clearly defined payment “benchmark” based on the rates we pay to in-network physicians within a geographic area.
In fact, the Congressional Budget Office has determined this method will save nearly $25 billion.
Yet, despite the obvious benefits and savings, misinformation about benchmark-based payments is threatening to derail this approach in favor of a complex and costly arbitration process that has the clear potential to raise costs for all consumers by giving doctors an additional incentive to stay outside of networks.
Benchmarks promote transparency
Hospital and specialty physician groups are claiming, for example, that setting a “benchmark” to pay surprise bills is like government rate-setting. That’s not true. In fact, this approach gives federal health officials the authority to develop a calculation methodology to promote transparency, but does not give the government the power to determine specific payment amounts. We would still be responsible for using our data to calculate individual market rates within geographic areas, specialties and lines of business.
Likewise, assertions that benchmarking would reduce payments below what doctors and hospitals need to stay in business also is inaccurate. A median in-network reimbursement approach would not impact a clinician or medical facility’s ability to operate, since we already pay well above Medicare rates. For example, nationally, the median reimbursement for anesthesiologists is currently 344 percent of what Medicare pays.
Benchmarks don’t erode networks
Another false claim is that creating a benchmark payment would deter us from contracting with doctors and hospitals. In fact, creating a benchmark payment will not erode our networks. We develop different types of networks based on the needs of our employers and consumers, and maintaining robust networks is central to how we serve our members.
Furthermore, regardless of how surprise billing is addressed, most states – including Nebraska – already have extensive network adequacy laws which will require us to continue contracting with specialists.
Getting hit with a surprise medical bill may be as devastating as the injury or illness that sent you to seek medical care. And while we all agree patients must be protected, it’s vital that lawmakers choose the clearest, simplest, most cost-effective and predictable way to address what are now opaque and unpredictable costs.