Health Insurance Industry Issues and Legislation

The No Surprise Act, part of the Consolidated Appropriations Act, goes into effect in January, 2022. The law will apply mainly to employers with self-funded health plans for whom state surprise billing laws do not apply, The Act includes many provisions designed to protect people from getting big bills for care from expensive, out-of-network providers at in-network hospitals, out-of-network emergency care providers, and out-of-network air ambulance services providers.

One key provision in the Act is the use of "baseball style arbitration" to determine how much the plan and patient will pay a provider. Interestingly, use of arbitration in states that already have well-established anti-surprise billing arbitration programs has been very low. One reason may be that with baseball style arbitration, one side wins and the other loses. Another is that the process of preparing and applying for arbitration can be time consuming and costly. Most importantly, outcomes have proven to be unpredictable and, to add insult to injury, the loser also pays the cost of the arbitration.

There are better, fairer ways than baseball arbitration to address bills from out-of-network providers, whether they come as a surprise or not. One is to have HHC Group's highly experienced attorney negotiators work with decision makers at the provider to get them to agree to accept an appropriate amount for the services rendered and seal the deal with a signed agreement. Another, in those cases where an agreement cannot be reached, is to take advantage of discounts HHC's PPO partners have negotiated with providers nationwide. Again, a fair outcome for all parties and no patient balance bill.

While controlling costs are important, member acceptance, engagement and satisfaction are all keys to successfully implementing an RBP plan. Secure, user friendly apps are an excellent member engagement and communication tools.

Specialty Drugs, like Harvoni, make up only 2.2% of all written prescriptions, but they account for 50% of all drug expenditures, and according to Express Scripts, they cost the U.S. health system as much as $100 billion per year. Medical costs make up almost half of that total. They can be reduced during the plan year without involvement of plans' PBM and with minimal changes to plan documents.

Sometimes savings can come in other forms other than dollars and cents. In the case of a 23-year-old blind female with Lyme disease, Osteoporosis, HHV-6, Uveitis, Juvenile Idiopathic Arthritis, and Bartonella, her mother requested personal assistance services to assist in household services, meal preparation and transportation. A Medicaid program from a Mid-Atlantic state initially deemed the request not medically necessary.