Health Insurance Industry Issues and Legislation

Anesthesiologists unit prices for surprise out-of-network claims, as well as in-network claims fell after enactment of No Surprise Billing Acts in California, Florida and New York. This according to a study published in JAMA. Importantly for self-funded groups, in New York where the law, like the federal No Surprise Act, calls for baseball arbitration to settle surprise bill disputes, OON surprise bill unit prices fell substantially after initially rising. Additionally, in-network Anesthesiologist services prices in New York decreased by 7% after its Surprise Billing Act went into effect.

Improper coding practices may well be costing commercial and government payers billions of dollars a year. Sutter Health has agreed to pay the federal government $90 million to settle allegations that it submitted inaccurate information on some of its Medicare Advantage (MA) beneficiaries. The settlement is the latest in a crackdown the federal government is instituting over MA coding that can contribute to overpayments. It comes less than a week after a major $575 million settlement was finalized on allegations the health system overcharged patients. HHC Group is here to help with claim and medical record level DRG Validation to root out costly coding errors before the claims are ever paid.

A new study shows that childbirth and infant hospitalizations are likely the most common source of surprise medical bills in the U.S. The study, published in the Journal of the American Medical Association, estimated that the average liability for a surprise medical bill was $744. The study comes as the federal government is taking steps to outlaw the practice. Surprise bills could range based on the types of service provided. For instance, a delivery had one or more potential surprise medical bills with an average liability of $900. The administration plans to issue more regulations on how an independent arbitration process will work for disputes between payers and providers over out-of-network charges.

HHC Group offers a free pre-screen to determine if potential savings are significant enough to justify an in-depth line item review. When they are, highly qualified, experienced nurse coders scrutinize every line on the claims to identify the errors, large and to ensure only the appropriate amount is being paid. And if the provider challenges any of the edits, we provide appeal support from day one at no extra charge.

HHC Group's Health Plan GPS (HPGPS) is a user-friendly mobile app and website for member engagement and communications, two keys to the ongoing success of any Reference-Based Pricing (RBP) plan. We give you the tools to engage with members and reduce both plan and member healthcare costs. Contact us to learn more.