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The No Surprises Act prohibits most surprise billing but notably does not apply to ground ambulance services. In this study we created a novel data set that identifies the ownership structure of ground ambulance organizations to compare pricing and billing between private- and public-sector ambulances, with a specific focus on organizations owned by private equity or publicly traded companies. Overall, we found that 28 percent of commercially insured emergency ground ambulance transports during the period 2014-17 resulted in a potential surprise bill. Our analysis illustrates that being transported by a private-sector ambulance in an emergency comes with substantially higher allowed amounts, patient cost sharing, and potential surprise bills compared with being transported by a public-sector ambulance. Further, allowed amounts and cost sharing tended to be higher for private equity- or publicly traded company-owned ambulances than other private-sector ambulances. These findings highlight substantial patient liability and important differences in pricing and billing patterns between public- and private-sector ground ambulance organizations. [ABSTRACT FROM AUTHOR]

In 2018 New Jersey implemented a final-offer arbitration system to resolve payment disputes between insurers and out-of-network providers over surprise medical bills. Similar proposals are being considered by Congress and other states. In this article we examine how arbitration decisions compare with other relevant provider payment amounts by linking administrative data from New Jersey arbitration cases to Medicare and commercial insurance claims data. We find that decisions track closely with one of the metrics that arbitrators are shown--the eightieth percentile of provider charges--with the median decision being 5.7 times prevailing in-network rates for the same services. It is not a foregone conclusion that arbitrators will select winning offers based on proximity to this target, although our findings suggest that it is a strong anchor. The amount that providers can expect to receive through the arbitration process also affects their bargaining leverage with insurers, which could affect in-network negotiated rates more broadly. Therefore, basing arbitration decisions or a payment standard on unilaterally set provider-billed charges appears likely to increase health care costs relative to other surprise billing solutions and perversely incentivizes providers to inflate their charges over time. [ABSTRACT FROM AUTHOR]

Patients treated at in-network facilities can involuntarily receive services from out-of-network providers, which may result in "surprise bills." While several studies report the surprise billing prevalence in emergency department and inpatient settings, none document the prevalence in ambulatory surgery centers (ASCs). The extent to which health plans pay a portion or all of out-of-network providers' bills in these situations is also unexplored. We analyzed 4.2 million ASC-based episodes of care in 2014-17, involving 3.3 million patients enrolled in UnitedHealth Group, Humana, and Aetna commercial plans. One in ten ASC episodes involved out-of-network ancillary providers at in-network ASC facilities. Insurers paid providers' full billed charges in 24 percent of the cases, leaving no balance to bill patients. After we accounted for insurer payment, we found that there were potential surprise bills in 8 percent of the episodes at in-network ASCs. The average balance per episode increased by 81 percent, from $819 in 2014 to $1,483 in 2017. Anesthesiologists (44 percent), certified registered nurse anesthetists (25 percent), and independent laboratories (10 percent) generated most potential surprise bills. There is a need for federal policy to expand protection from surprise bills to patients enrolled in all commercial insurance plans. [ABSTRACT FROM AUTHOR]

This study examines Texas independent dispute resolution payment outcomes for clinicians and compares them with arbitration benchmarks. [ABSTRACT FROM AUTHOR]

The article focuses on the Affordable Care Act (ACA) trying to enact policies inorder to reduce the out-of-network billing in a bid to protect the interests of the patients. It tells about the health insurance providers providing meaningful service to the patients which also promotes healthy competition in the industry.

The article reflects on the proposal of Republican Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana which excludes most of the tax cuts that were central to the previous repeal and replace efforts of the Affordable Care Act (ACA). It notes that the Graham-Cassidy plan would go even further than Better Care Reconciliation Act and the American Health Care Act (AHCA) in reducing health insurance coverage and affordability.

OBJECTIVES: Anesthesiology services are a focal point of policy making to address surprise medical billing. However, allowed amounts and charges for anesthesiology services have been understudied due to the specialty's unique conversion factor (CF) unit of payment and complex provider structures involving anesthesiologists and certified registered nurse anesthetists (CRNAs). This study compares payments for common outpatient anesthesiology services by commercial health plans, Medicare Advantage (MA), and traditional Medicare. STUDY DESIGN: Analysis of 2016-2017 claims from Health Care Cost Institute. METHODS: We derived allowed amount and charge CFs for commercial and MA claims using the base units assigned to each procedure code, time units, and modifiers. We computed the ratio of the allowed amount and charge CFs relative to the traditional Medicare CF. We described these payment measures by provider structure and network status. RESULTS: Mean in-network commercial allowed amount CFs for anesthesiology services ($70) are 314% of the traditional Medicare rate ($22), whereas mean commercial charge CFs ($148) are 659% of the Medicare rate. Commercial payments vary widely and are higher to anesthesiologists than to CRNAs and higher out of network than in network. MA plan payments align with traditional Medicare with payment parity between anesthesiologists and CRNAs, both in network and out of network. CONCLUSIONS: Common payment measures for anesthesia services--commercial allowed amounts, charges, or traditional Medicare--are highly divergent. MA plans' relatively low payments likely reflect the cost-containing influence of competition with traditional Medicare and MA's prohibition on balance billing. Out-of-network benchmarks for anesthesia services, such as the "qualifying payment amount" used in the No Surprises Act as a guidepost for arbitrators, may benefit from considering commercial payment differences across independent anesthesiologist, independent CRNA, or anesthesiologist-CRNA dyad provider structures. [ABSTRACT FROM AUTHOR]

An editorial is presented on the Affordable Care Act (ACA), based on which U.S. increased the per cent of Americans under the health insurance coverage in order to get universal coverage. It discusses how universal coverage can be attained by gaining Medicaid expansion, financial assistance to people buying at the health insurance marketplace.

The article discusses the impact of the American Health Care Act (AHCA) legislation passed by the U.S. House of Representatives on May 4, 2017. It states that the legislation would reduce the number of individuals with insurance coverage by 23 million. It mentions that it would reduce support to states that expanded Medicaid under Affordable Care Act (ACA).

Policy PointsOut‐of‐network air ambulance bills are a type of surprise medical bill and are driven by many of the same market failures behind other surprise medical bills, including patients' inability to choose in‐network providers in an emergency or to avoid potential balance billing by out‐of‐network providers.The financial risk to consumers is high because more than three‐quarters of air ambulances are out‐of‐network and their prices are high and rising. Consumers facing out‐of‐network air ambulance bills have few legal protections owing to the Airline Deregulation Act's federal preemption of state laws.Any federal policies for surprise medical bills should also address surprise air ambulance bills and should incorporate substantive consumer protections—not just billing transparency—and correct the market distortions for air ambulances. Context: Out‐of‐network air ambulance bills are a growing problem for consumers. Because most air ambulance transports are out‐of‐network and prices are rising, patients are at risk of receiving large unexpected bills. This article estimates the prevalence and magnitude of privately insured persons' out‐of‐network air ambulance bills, describes the legal barriers to curtailing surprise air ambulance bills, and proposes policies to protect consumers from out‐of‐network air ambulance bills. Methods: We used the Health Care Cost Institute's 2014‐2017 data from three large national insurers to evaluate the share of air ambulance claims that are out‐of‐network and the prevalence and magnitude of potential surprise balance bills, focusing on rotary‐wing transports. We estimated the magnitude of potential balance bills for out‐of‐network air ambulance services by calculating the difference between the provider's billed charges and the insurer's out‐of‐network allowed amount, including the patient's cost‐sharing. For in‐network air ambulance transports, we calculated the average charges and allowed amounts, both in absolute magnitude and as a multiple of the rate that Medicare pays for the same service. Findings: We found that less than one‐quarter of air ambulance transports of commercially insured patients were in‐network. Two‐in‐five transports resulted in a potential balance bill, averaging $19,851. In the latter years of our data, in‐network rates for transports by independent (non‐hospital‐based) carriers averaged $20,822, or 369% of the Medicare rate for the same service. Conclusions: Because the states' efforts to curtail air ambulance balance billing have been preempted by the Airline Deregulation Act, a federal solution is needed. Owing to the failure of market forces to discipline either prices or supply, out‐of‐network air ambulance rates should be benchmarked to a multiple of Medicare rates or, alternatively, air ambulance services could be delivered and financed through an approach that combines competitive bidding and public utility regulation. [ABSTRACT FROM AUTHOR]

The article discusses the disturbance in the individual health insurance coverage market caused by reforms in the Affordable Care Act (ACA). Particular focus is given to topics including an increase in the number of enrollments for insurance, raising premiums for health plans, and reimbursements for cost sharing reductions.