[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
HEARING ON REDUCED CARE FOR PATIENTS:
FALLOUT FROM FLAWED IMPLEMENTATION OF
SURPRISE MEDICAL BILLING PROTECTIONS
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56HEARING
before the
COMMITTEE ON WAYS AND MEANS
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 19, 2023
__________
Serial No. 118-FC14
__________
Printed for the use of the Committee on Ways and Means
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_______
U.S. GOVERNMENT PUBLISHING OFFICE
54-360 WASHINGTON : 2024
COMMITTEE ON WAYS AND MEANS
JASON SMITH, Missouri, Chairman
VERN BUCHANAN, Florida RICHARD E. NEAL, Massachusetts
ADRIAN SMITH, Nebraska LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania MIKE THOMPSON, California
DAVID SCHWEIKERT, Arizona JOHN B. LARSON, Connecticut
DARIN LaHOOD, Illinois EARL BLUMENAUER, Oregon
BRAD WENSTRUP, Ohio BILL PASCRELL, Jr., New Jersey
JODEY ARRINGTON, Texas DANNY DAVIS, Illinois
DREW FERGUSON, Georgia LINDA SANCHEZ, California
RON ESTES, Kansas BRIAN HIGGINS, New York
LLOYD SMUCKER, Pennsylvania TERRI SEWELL, Alabama
KEVIN HERN, Oklahoma SUZAN DelBENE, Washington
CAROL MILLER, West Virginia JUDY CHU, California
GREG MURPHY, North Carolina GWEN MOORE, Wisconsin
DAVID KUSTOFF, Tennessee DAN KILDEE, Michigan
BRIAN FITZPATRICK, Pennsylvania DON BEYER, Virginia
GREG STEUBE, Florida DWIGHT EVANS, Pennsylvania
CLAUDIA TENNEY, New York BRAD SCHNEIDER, Illinois
MICHELLE FISCHBACH, Minnesota JIMMY PANETTA, California
BLAKE MOORE, Utah
MICHELLE STEEL, California
BETH VAN DUYNE, Texas
RANDY FEENSTRA, Iowa
NICOLE MALLIOTAKIS, New York
MIKE CAREY, Ohio
Mark Roman, Staff Director
Brandon Casey, Minority Chief Counsel
C O N T E N T S
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OPENING STATEMENTS
Page
Hon. Jason Smith, Missouri, Chairman............................. 1
Hon. Richard Neal, Massachusetts, Ranking Member................. 2
Advisory of September 19, 2023 announcing the hearing............ V
WITNESSES
Seth Bleier, Vice President of Finance, Wake Emergency Physicians
Professional Association....................................... 3
James Bobeck, President, Federal Hearings & Appeals Services,
Inc............................................................ 10
Diane Spicer, Supervising Attorney, Community Health Advocates,
Community Services Society..................................... 16
Jeanette Thornton, Executive Vice President of Policy and
Strategy, America's Health Insurance Plans..................... 22
Jim Budzinski, Executive Vice President & Chief Financial
Officer, Wellstar Health System................................ 29
QUESTIONS FOR THE RECORD
Member Questions for the Record and Responses from Jeanette
Thornton, Executive Vice President of Policy and Strategy,
America's Health Insurance Plans............................... 119
PUBLIC SUBMISSIONS FOR THE RECORD
Public Submissions............................................... 183
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REDUCED CARE FOR PATIENTS: FALLOUT FROM FLAWED IMPLEMENTATION OF
SURPRISE MEDICAL BILLING PROTECTIONS
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TUESDAY, SEPTEMBER 19, 2023
House of Representatives,
Committee on Ways and Means,
Washington, DC.
The committee met, pursuant to call, at 10:07 a.m., in room
1100, Longworth House Office Building, Hon. Jason T. Smith
[chairman of the committee] presiding.
Chairman SMITH. The committee will come to order.
Three years ago, Congress passed the bipartisan No
Surprises Act to end surprise medical bills for good. American
patients were in desperate need of these protections, as too
many had come face to face with medical bills from being
treated without their knowledge by an out-of-network doctor. It
left them on the hook for tens and even hundreds of thousands
of dollars in surprise medical expenses.
This law has seen success in ending that crisis.
Unfortunately, the new surprises for patients have come in the
form of medical staff shortages, longer wait times, and fewer
choices because of the Federal Government's flawed
implementation of the law.
Three years ago, the Ways and Means Committee led the
bipartisan effort to draft the No Surprises Act. But agency
rulemaking has unfortunately ignored congressional intent. It
has created a tilted dispute resolution process that has left
medical providers paying more to participate in a process that
often forces them to accept artificially low payments with no
enforcement guarantee. It has also led to legal challenges that
have resulted in significant backlogs and left the process
clouded in uncertainty.
This law's implementation has made the very problem it
intended to fix worse, resulting in more medical providers no
longer covered under health insurance networks. This leaves
Americans paying more to access fewer doctors than ever before.
All of this makes it harder for patients to access quality care
as health care facilities struggle to even keep their doors
open, particularly in rural areas. Consequently, emergency room
wait times have doubled since 2020.
The rules implementing the No Surprises Act have inflamed
an existing staff shortage in an industry where having too few
people can be a life-and-death matter. Right now, 600 rural
hospitals are at risk of shutting down. Left unchanged, these
Federal rules will continue to lead to less access to quality
care. Patients are the ones most impacted by closed hospitals
and long wait times for critical services. Rural and urban
areas both face a health care shortage.
At the same time, the agencies have not bothered to
implement the advanced explanation of benefits, one of the key
reforms that members of this committee fought to include in the
No Surprises Act. Part of ending surprise billing is ensuring
that people know the price of health care services before they
walk in the door. Before a patient sees their doctor, patients
should be told how much they will pay for the care they
receive. And yet patients still have yet to benefit from this
protection to which they are legally entitled.
While Congress made strides in stopping surprise medical
bills, the fallout of this law's implementation demands our
oversight. And I am encouraged that there is interest from both
parties in seeing this bipartisan law fairly implemented. It is
unacceptable that a major win for Americans can be turned into
a scenario where medical providers struggle to keep their doors
open, patients lose access to quality care, and the basic
principle of knowing the price of the care they will receive
has yet to be realized.
I look forward to working with my colleagues on both sides
of the aisle to make the promise of the No Surprises Act a
reality.
Chairman SMITH. And I am pleased to recognize Ranking
Member Mr. Neal for his opening statement.
Mr. NEAL. Thank you, Mr. Chairman, and I am pleased that
you have called this hearing this morning.
And I want to thank our witnesses for being here, as well,
and I certainly look forward to hearing from all of you.
I know what Kevin Brady and I intended when we helped to
write this law. And the implementation so far has been a
disappointment, despite the fact that we continue to prevail in
court decisions.
For too long, millions of Americans have struggled with
unexpected out-of-pocket health costs that have caused anxiety
and hardship for their families. When we wrote this law, we
weren't targeting anybody, we weren't looking for a victim, and
we weren't being punitive. In 2020, the Ways and Means
Committee expanded a long legacy of patient-first policies,
leading the charge to end the uncertainty of surprise medical
billing. We brokered the No Surprises Act, putting an end to
surprise medical billing while enhancing consumer protections
and empowering patients with more information about the cost of
their care. Unanimously, this committee put out the appropriate
version of the legislation.
Ways and Means Democrats continue to want what is best for
America's patients. That means an accessible, affordable, and
transparent health care system with robust protections for
consumers. The No Surprises Act builds on these priorities,
providing for an impartial, structured process to settle
payment disputes between insurers and providers with strong
conflict-of-interest protections, timely decisions, and clear
criteria for resolution.
Unfortunately, implementation of this law has strayed from
Congress and its original intent, especially as it relates to
the dispute resolution process. When drafting the law, we
worked to ensure fairness between the parties involved in the
payment disputes and we carefully specified factors that should
be considered during the Independent Dispute Resolution
process.
The IDR process was developed through robust, extensive,
congressional consideration in this committee for two years
before the No Surprises Act took place. As written, this law
carefully avoids any one single factor unduly influencing the
dispute resolution process. Despite this consideration, the
final rule for the No Surprises Act strays from the law as
written in favor of an alternate approach that overwhelmingly
favors one factor instead of the more balanced consideration
that this committee and Congress fully intended.
Democrats have fought to bolster patient protections and
build a healthier, stronger America. We delivered the historic
Affordable Care Act, and now we are raising the first
generation of Americans who didn't know a life without patient
protections and the access that we provided and came through
the Affordable Care Act. Now more Americans have health
coverage than ever before, and Ways and Means Democrats are
committed to building on the progress that we have made by
continuing to lower health care costs and to promote price
transparency. That is why we delivered the No Surprises Act--
again, in a bipartisan manner--and we will continue to work
closely with the Administration to ensure this law is
implemented as this committee and as Congress intended.
It is time to get this back on track and ensure that one of
the greatest consumer protection reforms in our country's
history is fully implemented as the Ways and Means Committee
intended.
Mr. NEAL. With that, Mr. Chairman, I yield back my time.
Chairman SMITH. Thank you, Mr. Neal. I will now introduce
our witnesses.
Dr. Bleier is the vice president of finance at the Wake
Emergency Physicians Professional Association.
We have Mr. Bobeck as the president of Federal Hearings and
Appeals Services.
Ms. Spicer is the supervising attorney at Community Health
Advocates.
And Ms. Thornton is the executive vice president of policy
and strategy at America's Health Insurance Plans.
And Mr. Budzinski is the executive vice president and chief
financial officer of Wellstar Health System.
Thank you all for joining us today. Your written statements
will be made part of the hearing record, and you each have five
minutes to deliver your opening remarks.
Dr. Bleier, you may begin when you are ready.
STATEMENT OF SETH BLEIER, MD, VICE PRESIDENT OF FINANCE, WAKE
EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION
Dr. BLEIER. Chairman Smith, Ranking Member Neal, and
members of the committee, thank you for the opportunity to
testify today in this hearing on the implementation of the No
Surprises Act.
I am an emergency physician from Raleigh, North Carolina,
and I currently serve as the vice president of finance for Wake
Emergency Physicians PA, or WEPA. I am also a member and fellow
of the American College of Emergency Physicians, ACEP, which
represents nearly 40,000 members as well as the North Carolina
College of Emergency Physicians. On behalf of our practice and
our specialty as a whole, we appreciate the committee's ongoing
commitment to ensuring the law is implemented fairly and
according to congressional intent.
Wake Emergency Physicians is an emergency medicine practice
serving central North Carolina. Since our founding in 1992, we
have always been physician-owned, and have never had any
corporate or private equity backing or interests. Every owner
regularly works in the emergency department. WEPA currently
employs more than 200 dedicated emergency medicine specialists
comprised of about 120 residency-trained, board-certified
emergency physicians and 95 advanced practice providers. We
serve in 11 different emergency departments across 4 different
hospital systems in the region. Four of those emergency
departments are located in rural communities. Our goal is and
has always been to be in-network with every payer. And until
the first regulations for the NSA were issued, we were in-
network with all four major insurance carriers in our area of
the state.
To be clear, the No Surprises Act is a critical bipartisan
accomplishment that removes patients from the middle of billing
disputes between physicians and insurers, and we strongly
supported this goal. In an emergency where seconds and minutes
are often a matter of life or death, patients should never have
to think about their insurance coverage or whether they will
receive a bill that they did not expect.
Beyond these important patient protections, the law
established an equitable solution to resolve billing
disagreements, at least in intent. Unfortunately, the
implementation of the law to date has proven to be
exceptionally challenging for smaller practices like ours.
While we have so far been able to weather some of the impacts,
if these challenges are not resolved we are deeply concerned
that practice models like ours may not be viable in the near
future, and access to lifesaving emergency care may be severely
affected, especially for rural and underserved patients.
As I noted earlier, WEPA had historically been in-network
with all major carriers in our region of North Carolina. Most
of these contracts had been in place for at least a decade
without any changes or updates. In November 2021, we and many
other physician groups in the state received a letter from one
of these insurers demanding significant cuts to our contracted
rate. The letter explicitly cited the interim final rule on the
NSA as justification for the reduction and stated that, if we
did not agree to new payment terms, our contract would be
terminated.
Thankfully, this did not come to pass, but we have since
had two other payers unilaterally terminate a longstanding
contract. These insurers are now paying at rates that are up to
70 percent less than our previous contracts for what are now
out-of-network services. This is just not sustainable for a
practice like ours. And, if these conditions persist, we may be
forced to substantially reduce staffing hours, cut positions,
or potentially even withdraw contracts at certain hospitals.
Adding to this burden is the fact that the IDR process has
been virtually inaccessible for small practices once we are out
of network. Many smaller practices have been advised by their
billing contractors to avoid going through the IDR process
altogether, as the costs outweigh any potential benefit. We
cannot afford to challenge every underpayment when the non-
refundable portion of the arbitration fee is $50, much less
$350. Even though the government statistics show providers
prevail the majority of the time over insurers in IDR, to date
we have only submitted about 400 IDR claims. Batching rules,
the IDR processing backlog, and cases where payers are simply
not paying at all have also contributed to this substantial
burden.
Now that at least some of these issues have been resolved
due to recent court decisions and the resulting pending
regulatory changes, we do hope to re-engage with the IDR
process when the portal reopens. But all of this takes up
valuable time and resources that we would much rather devote to
patient care. We would rather not be forced to submit IDR
claims. We want to go back to being in-network with every
payer, and our long-lasting contracts in place prior to passage
of the NSA show that we always did our best to be in-network.
WEPA is only one practice, but, sadly, we know our
experience is not unique. We believe the No Surprises Act
clearly struck a delicate balance as to not tip the scales too
far in favor of any party, but the regulations have not been
consistent with the law that Congress passed.
Thank you once again for your attention to these issues and
for the opportunity to be here to share our experience. I look
forward to any questions you may have.
[The statement of Dr. Bleier follows:]
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Chairman SMITH. Thank you.
Mr. Bobeck, you are now recognized.
STATEMENT OF JAMES BOBECK, PRESIDENT, FEDERAL HEARINGS AND
APPEALS SERVICES, INC.
Mr. BOBECK. Chairman Smith, Ranking Member Neal, and
members of the committee, my name is James Bobeck, and I am the
president of Federal Hearings and Appeals Services, a certified
Independent Dispute Resolution Entity commonly known as an
IDRE. Thank you for the opportunity to speak to the committee
today regarding the implementation of the No Surprises Act and
the Independent Dispute Resolution process.
FHAS is a certified, veteran-owned small business from
Pennsylvania. We are an accredited, independent review
organization possessing ISO certification. We are a leading
provider of arbitration dispute services and health care
reviews for Federal and state agencies. We have adjudicated
over 100,000 health care disputes in the past year and over 3.1
million decisions in the past 27 years. FHAS was one of the
first groups certified by CMS as an IDRE entity.
The No Surprises Act prohibits surprise medical billing in
certain circumstances. Additionally, health plans must make an
initial payment to providers based on the qualifying payment
amount, which is the median rate for a particular service. If
the provider feels that amount is too low, providers can avail
themselves of the Independent Dispute Resolution process, and
an IDRE will determine the final payment amount.
Over the past two years, the Department of Health and Human
Services, Department of Labor, and the Department of Treasury,
collectively known as the Departments, have promulgated Federal
rules implementing various provisions of the No Surprises Act.
Most notably, the Departments issued rules regarding how an
IDRE should adjudicate payment disputes.
The program rules are determined solely by the Departments,
and the IDREs are required to follow those rules in carrying
out their designated functions. Most importantly, these
functions include adjudicating payment determinations based
upon the parties' submitted offers and supporting evidence.
Notably, the IDRE must choose either the provider or the
payer-submitted offer, which is commonly known as a baseball-
style arbitration.
The Departments published their latest statistics on the
IDRE process on April 27, 2023. Those statistics cover the
timeframe from the start of the process back on April 15, 2022
through March 31, 2023. In that time, disputing parties
initiated 334,828 disputes. Entities rendered payment
determinations in 42,158 of those disputes. FHAS alone issued
13,500 determinations in that timeframe, which represents about
32 percent of the overall payment determinations.
Additionally, 39,890 cases were ultimately determined
ineligible for the IDRE process, and eligible cases primarily
resulted from parties' non-compliance with the Departments'
batching rules, which are rules regarding how parties can
combine multiple cases into one dispute. IDR Entities also
closed disputes for other reasons, such as the parties may come
to a settlement of the matter, or they simply withdraw their
case.
Throughout the past year, Federal court rulings have
vacated certain provisions of the Departments' rules. In
response, we have made on several occasions a temporary
suspension of the IDRE program, as CMS attempts to formulate
new rules regarding that process. Currently, the dispute
resolution process has been suspended since August 3, 2023, and
during this suspension parties cannot submit new cases through
the CMS portal and IDREs cannot adjudicate any payment
determinations.
The dispute resolution portal must be opened immediately to
allow dispute filing. Prior to the shutdown, parties routinely
filed in excess of 40,000 cases per month. Providers and payers
rely upon the portal's operation to finalize payment
determinations. Without payment determinations, parties cannot
resolve their disputes, providers cannot receive any payment
for their services, and payers cannot render required payments
to providers.
Thank you for the opportunity again to appear before the
committee. FHAS is committed to providing timely arbitration
services, and we look forward to continued engagement with the
committee.
[The statement of Mr. Bobeck follows:]
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Chairman SMITH. Thank you.
Ms. Spicer, you are now recognized.
STATEMENT OF DIANE SPICER, SUPERVISING ATTORNEY, COMMUNITY
HEALTH ADVOCATES, COMMUNITY SERVICES SOCIETY
Ms. SPICER. Chairman Smith, Ranking Member Neal, and
distinguished members of the committee, thank you for holding
today's hearing to examine the impact of the No Surprises Act.
My name is Diane Spicer. I work at the Community Service
Society of New York, or CSS. CSS has been an unwavering voice
for low-income New Yorkers for over 175 years. CSS administers
the Community Health Advocates Program, New York State's
Designated Health Insurance Consumer Assistance Program,
through a live answer help line and in partnership with over 20
community-based organizations located throughout the state.
Since 2010 Community Health Advocates has helped over half-a-
million New Yorkers enroll in and use health insurance,
negotiate medical bills, and otherwise access free or low-cost
health care, saving them $180 million.
As the supervising attorney of Community Health Advocates,
I have had the unique opportunity to view the implementation of
both the New York State out-of-network surprise billing law and
the Federal No Surprises Act.
In 2014, the State of New York passed the surprise billing
ban, setting up a baseball-style arbitration that kept the
patient out of the middle of payment disputes at the urging of
CSS on behalf of a coalition of consumer advocates. CSS was
encouraged to see Congress follow New York's model in 2020 and
ban surprise medical bills for federally-regulated plans.
We are grateful for the work done in Congress and in our
home state of New York to address surprise bills. Nevertheless,
we still field over 20 calls per month from patients with
questions. The health care system can be extremely complicated
to navigate for even the most well-versed among us. Advocates
spend a lot of time helping patients understand the complicated
rules and processes necessary to determine whether they have
received a surprise bill and how to appeal to be held harmless.
Prior to the passage of New York's law, CHA fielded
hundreds of calls a year from consumers who faced surprise
bills. A typical case involved the admission of a client to an
emergency room for painful kidney stones. The emergency room
transferred the client to the urology department, who performed
surgery. All of their providers were in-network except the
anesthesiologist, leaving the client with the classic surprise
bill. New York's out-of-network surprise billing law addressed
these classic cases for our state-regulated insurers.
We at CHA were delighted to see the enactment of the
Federal No Surprises Act because it made additional
improvements to what we had already achieved in New York,
including providing protections against air ambulance bills,
addressing network directory misinformation, affording
protections to consumers in federally-regulated ERISA plans,
and, importantly, covering the circumstances of when a provider
incorrectly tells a patient that they are in-network.
Claudia Knafo, a concert pianist who needed neurological
surgery, is a classic example of this issue. Claudia did
everything right. She found a hospital and a surgeon who were
in-network, cleared everything with her insurance, and
proceeded with her surgery. But her surgeon's office had
misinformed her that he was in-network when he, in fact, was
not. She was stranded with a $35,000 bill. Her situation is now
covered by the NSA, which requires providers to issue notice
and consent waiver forms in advance of treatment when they are
out-of-network.
With that said, our clients still struggle every day with
the implementation of our state law and the NSA. Specifically,
the structure of the law leaves patients vulnerable to surprise
bills in several ways.
The first, the process of determining which bills are
covered and appealing a surprise bill, is too complicated for
many consumers to understand.
Second, plans do not automatically hold consumers harmless
for surprise bills, and many health care providers remain
uneducated about the law and continue to balance-bill patients.
And third, providers may use the notice and consent form
inappropriately. Loopholes also remain in the law. For example,
there have been operational issues with the rollout of the
notice and consent form waiver. We have seen instances where
providers use the consent form inappropriately.
For example, in a recent case a consumer whose primary
language was not English was told his varicose vein surgery
would not be performed unless he signed the form. Because he
needed surgery and did not understand the form, he signed the
form shortly before surgery and paid a $6,000 deposit out of
pocket. His plan's explanation of benefits later stated that
his claim was reduced and, because of the protections of the
NSA, he would owe only his in-network cost sharing of $18.
However, the patient already signed the form, and thus it was
incorrectly required to pay. It will be hard to reclaim this
amount.
All of us sign numerous pages of forms when we go to the
doctor and get procedures, sometimes on electric devices, and
few of us have the capacity to understand the ramifications of
signing the form.
I would like to close by saying we are deeply proud of the
work we do. Patient confusion around health care costs
continues to grow, despite Federal and state protections. We
urge Congress to work together to restore funding to vital
Health Insurance Consumer Assistance Program, so that together
we can help improve the patient experience and help them
through the very complicated processes of determining whether
or not they have a surprise bill and appeal to be held harmless
for that bill. Thank you.
[The statement of Ms. Spicer follows:]
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Chairman SMITH. Thank you.
Ms. Thornton, you are now recognized.
STATEMENT OF JEANETTE THORNTON, EXECUTIVE VICE PRESIDENT OF
POLICY AND STRATEGY, AMERICA'S HEALTH INSURANCE PLANS
Ms. THORNTON. Good morning, Chairman Smith, Ranking Member
Neal, and distinguished members of the committee. I am Jeanette
Thornton, executive vice president for policy and strategy at
AHIP.
I testified here in May 2019 as this committee and others
in the House and Senate were debating legislation to end the
practice of surprise medical billing. As I said then, every
American deserves affordable, high-quality coverage and care,
and surprise medical billing was a barrier to that goal. At
that time, approximately one in five emergency department
visits resulted in a surprise bill. Going to the emergency
department or being treated at the hospital meant uncertainty
and worry not only about your health, but also that you would
get an unexpected bill that you couldn't afford.
Enacted with strong bipartisan support in Congress, the No
Surprises Act had--has resulted in peace of mind and financial
security. But the promise of the No Surprises Act remains--has
not been completely fulfilled. Work remains to improve the
dispute process, lower health care costs, and grow the number
of in-network providers.
It is first worth reflecting on how far we have come since
the No Surprises Act was passed. The No Surprises Act has
prevented one million surprise bills per month. To put it
simply, that is 20 million bills since January 2022. Patients
in every state are protected from most surprise medical bills.
Bill charges, often exorbitant amounts, no longer dominate as
the payment demand for out-of-network care. Patients see lower
and more predictable out-of-pocket costs because of the
Qualifying Payment Amount, or QPA, is based on the median of
market rates.
There is more good news. For nearly 9 in 10 out-of-network
claims subject to the law, the No Surprises Act works without
issue. An initial payment is made by the health plan to a
provider or hospital, typically based on the QPA, and this
amount is accepted without any dispute.
The dispute process was meant to be a backstop, a recourse
for providers and hospitals to utilize in limited instances
where market rates for health care items and services may not
be applicable. But today this process is costly, inefficient,
and heavily weighted in favor of initiating parties, with them
prevailing in 71 percent of disputes.
We share your frustration in how the dispute resolution
process has rolled out. More cases have gone to IDR than were
ever contemplated, 14 times more, highly concentrated in just 5
states. Providers are submitting claims that are ineligible.
The overwhelming majority of claims are from a small subset of
physician staffing and billing companies and one air ambulance
company. Repeated litigation from the Texas Medical Association
and others has created uncertainty and caused repeated starts
and stops and hindered the regulators in developing a process
that works.
Our goal is to have more health care providers,
particularly facility-based providers, join plan networks so
that this IDR process is rarely used. The success of our
business model depends on having large networks of high-
quality, high-value health care providers.
A lack of sufficient information has at times delayed
payments. But despite claims to the contrary, this is not
intentional on the part of health insurance providers. In fact,
withholding payments really works against our business model.
We encourage the regulatory agencies to continue their work
to ensure the Federal process is efficient, reduces ineligible
claims, and facilitates on-time and accurate payments. It is
critical that unbiased IDR Entities are evaluating factors in a
uniform and transparent manner that aligns with the intent of
the law.
Thankfully, today patients no longer have to worry about
receiving a surprise medical bill when they return home from
the hospital or emergency department. And for when this does
happen, we believe there is a path forward to make this dispute
process work as intended in a way that reduces health care
spending if all stakeholders work together.
Thank you for the opportunity to testify. AHIP and our
members appreciate the continued bipartisan commitment to
protecting patients from surprise medical billing and lowering
health care costs.
[The statement of Ms. Thornton follows:]
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Chairman SMITH. Thank you.
Mr. Budzinski, you are now recognized.
STATEMENT OF JIM BUDZINSKI, EXECUTIVE VICE PRESIDENT AND CHIEF
FINANCIAL OFFICER, WELLSTAR HEALTH SYSTEM
Mr. BUDZINSKI. Thank you, Mr. Chairman, Ranking Member
Neal, distinguished members of this committee.
Consistent with the introduction, my name is Jim Budzinski.
I am the chief financial officer of the Wellstar Health System
from the great State of Georgia.
The Wellstar Health System is a not-for-profit, community-
based, 11-hospital system serving 1.5 million Georgians. The
Wellstar Health System operates----
Chairman SMITH. Could you just pull the mic a little bit
closer?
Mr. BUDZINSKI. Yes, sir, thank you.
The Wellstar Health System operates 6 of the state's 20
busiest emergency departments. We provide more uncompensated
care than any other system in Georgia, totaling nearly $1
billion in our last fiscal year alone.
Wellstar supports the No Surprises Act, which protects
patients from surprise emergency room bills. However, we
appreciate the opportunity to share with you the unintended
consequences of implementation of the Act, which have
negatively affected the people and communities whom we serve.
Health plans have been able to narrow their networks such
that their enrollees often no longer have access to in-network
emergency care in many of our communities and rely on a broken
system to lower reimburse--to hospitals below sustainable
levels.
One of our biggest problems with the implementation is the
broken Independent Dispute Resolution process, which
significantly disadvantages hospitals and health systems. The
problems are the result of regulatory interpretations that have
biased the process in favor of health plans, and bogged it down
such that there is a long wait time for adjudication of
submissions.
For Wellstar, the IDR entities have resolved only 7 percent
of our roughly 8,000 requests for determination. The estimated
reimbursement on our requests exceeds $40 million, funds owed
to us by some of the largest health insurance companies in
America. At this rate, it will take over 20 years to resolve
all of our outstanding requests.
We are also concerned that the implementation of the Act
has also encouraged bad insurer behavior. Now, without
consequence, insurers are able to sell insurance in counties in
which they have no in-network hospital emergency departments.
While the Act intended for hospitals and insurers to work
together for appropriate reimbursement, health plans are
ignoring this provision of the law and regulations.
For example, one national insurer with whom we are out of
network reduced our reimbursement by nearly 50 percent
immediately after following the implementation of both Federal
and state surprise billing laws. This change represented a $50
million reduction in reimbursement to our organization.
Further, another national insurer recently threatened to
terminate our 20-year-plus contract unless we agreed to a 20
percent decrease in payment. This demand would represent a
reimbursement loss of over $4 billion over the next 10 years at
a time when our cost of care has increased because of the
pandemic over 25 percent due to workforce shortages and
increases in supply and drug costs.
While we were able to resolve this matter with only a $1
billion cut over the next 10 years, this emboldened behavior by
insurers is not unique to Wellstar, and it is one of the
reasons for the median health system operating margins being
negative, as reported by Standard and Poor's just last month.
For Wellstar, these cuts in emergency reimbursement jeopardize
the services we provide to our communities, including those
sole community hospitals in our system, some of which now
operate at deficits of 14 to $19 million annually. This result
was not the intent of Congress when it passed the Act.
Mr. Chairman, Ranking Member Neal, members of this
committee, we have appreciated the opportunity to share our
thoughts with you today. Our time together here is limited, so
I would refer to our written testimony for more information.
This concludes my remarks, and I would be happy to take any
questions. Thank you.
[The statement of Mr. Budzinski follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman SMITH. Thank you, sir. We will now proceed to the
question-and-answering--answer session, and I will begin.
Dr. Bleier, one of the areas of fallout that we have seen
from the flawed implementation of the No Surprises Act is how
the regulations incentivize health insurers to limit the number
of physicians with whom they have contract agreements to cover
their services. What does that do for patients' access to care,
especially for those living in rural and underserved areas who
already suffer from a lack of care options?
Dr. BLEIER. It makes it much more challenging for those
patients, as well as the providers taking care of them. If
physicians are excluded and become out of network, basically,
that reduces their reimbursement. And their reimbursement is
what covers the staffing hours, adding additional provider
coverage to those needing emergency departments. And by
reducing physician hours, physician--emergency medicine
provider hours, that reduces the care that those patients need.
So it has a downstream effect, unfortunately.
Without that additional reimbursement, we aren't able to
potentially provide the same level of care that we ordinarily
would want to to those rural emergency departments who are
already suffering for a number of different reasons.
Chairman SMITH. Mr. Bobeck, as an Independent Dispute
Resolution Entity, you have a front row seat to how this
process is operating. We have heard concerns about how the
law's implementation has complicated the dispute resolution
process and has contributed to a backlog of claims. How has
this process gotten off the rails, and what can be done to
ensure that dispute resolution ultimately is fair for all
parties?
Mr. BOBECK. Mr. Chairman, three big things that we would
like to say at the beginning are when it comes to some of the
matters regarding the implementation and then how it moves
along the process, the words ``misunderstanding,''
``miscommunication,'' and ``misinformation'': parties not
understanding how the process was intended to work;
miscommunication among the parties about the information they
need to provide each other to even try to get to reasonable
offers; and then ultimately, the misinformation that
occasionally goes out about how they just actually put cases
into the system.
The biggest thing that could happen--and it is starting to
happen right now--is that parties are getting much better at
formulating their responses, communicating with each other, and
then ultimately getting more cases eligible for the process and
decisions being made. Right now, this process still is in its--
just over one year that it has been going on.
It was set up for a certain amount of cases, and certainly
that has gone overboard. But at the same time it is set up to
move forward on this, and parties, providers, and the IDREs are
working much better together to get cases moving along.
Chairman SMITH. Mr. Budzinski, emergency department wait
times have more than doubled since 2020, and more than 600
rural hospitals are currently at risk of a closure. As a
hospital administrator, how have you seen the implementation of
the No Surprises Act affect the ability of hospitals to
maintain appropriate staff and critical emergency services for
patients?
Mr. BUDZINSKI. Thank you, Mr. Chairman. There is no
question that the implementation of the Act has had impacts on
organizations such as ourselves. The impact reduces resources,
and administrators then have to allocate their scarcer
resources to staffing and other activities. So there clearly is
a direct correlation. Whenever resources are reduced, then the
allocation of those reduced resources impact care in some way,
shape, or form.
Chairman SMITH. Ms. Spicer, thank you for your work helping
patients understand our complex health care system. Three or
more years ago, patients across the country would still be
receiving surprise medical bills. You have been firsthand--you
have seen firsthand how the No Surprises Act has largely
protected patients from this practice. While the implementation
hasn't been perfect, can you speak to how the law has benefited
patients?
Ms. SPICER. Thank you, Mr. Chairman. The law has benefited
patients tremendously. It goes beyond many--many states don't
have--didn't have surprise billing laws before the NSA, but
goes--this--the NSA goes even beyond the protections that are
in your average state surprise billing law, as in New York's
surprise billing law.
Many, many, many of the cases that I had on my help line
prior to the No Surprises Act were cases that were unaddressed
by New York's law, specifically network directory
misinformation. When you call your health plan and you ask them
who is in-network, or you look at their online directory and it
is--the information is outdated, hundreds and hundreds of cases
of consumers who just get bad information from providers or
plans about the network are now protected.
And so many more protections in terms of air ambulance,
also the--just the resolution processes, though complicated for
consumers to avail themselves of, are available for them to
appeal surprise bills and even go through the internal appeals
process and to external appeal with those bills.
Chairman SMITH. Ms. Thornton, the rulemaking surrounding
implementation of the No Surprises Act has been subject to
multiple legal challenges. This has naturally disrupted the
dispute resolution process, delayed payments, and thrown a
blanket of uncertainty over the whole law. How are health
insurers doing their part to alleviate the current backlog of
claims and ensure that payments are made in a timely manner?
Ms. THORNTON. Thank you for the question, Mr. Chairman. You
are definitely correct. All of the repeated starts and stops
from the litigation, as well as the changes in regulations have
really created a lot of uncertainty with health plans with
regard to how they have to plan their staffing and operations
for when the arbitration process brings--comes back online.
There is also a concern that when the process does go
online, there have been such a large backlog of cases that we
will not be able to meet the required deadlines and payment
timelines because there is such a backlog and so much within
the system.
And finally, you know, we are really concerned around what
the updated rules will look like, and whether that will mean
that the process becomes more unbiased towards the--more biased
towards the providers versus the health plans. I think our goal
is a very balanced process. We would love to see a 50/50
outcome, right? Some cases will be decided with providers, some
to plans, and that means the process is working well.
Chairman SMITH. So how are health insurers ensuring that
payments are made in a timely manner?
Ms. THORNTON. That is a really important question, and we
understand how important for providers and their cash flow that
they are getting paid in a timely manner.
One of the really important things about the Act is that
you built in the requirement that we have to make an initial
payment within 30 days. So providers are getting paid upon
receipt of a claim within 30 days.
I think what is often at issue here is how quickly health
plans are making payments as a result of an IDR decision. As I
said in my statement, there have been at times delays in those
payments, and that really has to do with some challenges with
the implementation technology, as well as very difficult
deadlines and having to go through, in some cases, thousands
and thousands of lines of code, match it up to our systems, and
then make those payments on time.
But we are certainly--really strive to meet the deadlines
that are provided.
Chairman SMITH. Mr. Neal is recognized for questions.
Mr. NEAL. Thank you. Before I begin my opportunity to
question our witnesses, I want to take a moment to remind
members of the committee of the role that this committee played
in ensuring that Congress would pass a strong and balanced
law--emphasis on ``balanced.'' And that is what we did.
The idea was, almost like binding arbitration, to make sure
that people of goodwill and good intentions would try to avoid
the process at the end, and it would bring them to a better
decision-making process at the beginning; this was done in a
bipartisan manner, and it unanimously passed this committee. It
was a good product that passed out of here because of the work
of this committee and the product that became law.
Dr. Bleier, I have heard from many providers across the
country that implementation of the No Surprises Act has led to
financial uncertainty. While HHS revises the regulations to
comply with the law as enacted, other peripheral issues are
causing financial difficulty. As with implementation of any new
and sweeping law, there are certainly growing pains. I have
been pressing HHS at the top all the way through the members of
the staff on many issues.
So beyond the need to revise the standard and the dispute
entities that are trying to comply with the law, can you
summarize what other issues in the No Surprises Act are
affecting payments to the Wake Emergency Physicians?
Dr. BLEIER. Sure. We had been in-network, as a reminder,
with all of the major carriers in our area for years. We never
went back to them and asked for an increased rate. Our
contracts did not have any cost-of-living indexes, no
inflationary adjustments year over year. They were tied to
Medicare fee schedules from years before that.
In addition, we have also seen significant decrease in
payments from some insurers over the years not only due to
inflation, but also due to the fact that a lot of the health
care expenditures are being pushed to patients in high-
deductible plans. Despite that, we never went back and asked
for more. We have always intended to be in-network with all of
these providers. Then--with all of these insurers, excuse me.
Then the No Surprises Act comes out, and suddenly we are
getting letters from insurers saying, ``You are out of network
unless you take a 40 percent reduction,'' sometimes more. Since
the passage of the law, we have been kicked out of network
unilaterally by two different insurers, and are seeing
reductions in reimbursement from one of them by 70 percent from
our previous contracted rates, which we believe were very fair
at the time, because at no point up until the No Surprises Act
came out did any of the insurers come back and ask for us to
adjust our rates. They were evergreen year over year.
So, because of the No Surprises Act, we have subsequently
been kicked out of network. We have seen a tremendous decrease
relative to what we believe were fair market rates. And in
addition, there is no recourse for action due to the IDR issues
that have been ongoing.
So even when we win in an IDR case, we effectively lose due
to the fees associated with it, and then we do not get paid
afterwards.
Mr. NEAL. Thank you. So our intent here was not to be
punitive, not to pick on anybody, and not to favor one side or
the other. It was, as I indicated, a balanced piece of
legislation, I think, to provide ample opportunity to all sides
of the dispute.
So, Ms. Spicer, let me thank you for your testimony. I'm
grateful for the good work you do every day. And you report
that patients remain confused about whether their medical bills
are covered or not and, if they are, how much cost-sharing they
are responsible for. Why do you think patients are still
receiving bills they should be protected from, and how would
you suggest that patients help navigate this process to protect
them from illegal surprise billing practices?
Ms. SPICER. Thank you for the question. Health plans--
consumers are not always held harmless, as they should be under
the No Surprises Act. Consumers still receive surprise medical
bills. And what we do at Community Health Advocates is help a
consumer who doesn't know they have a surprise bill, but calls
to say, ``I have a bill I can't afford,'' or, ``Why didn't my
health insurance pay,'' and then we go through a complicated
process to help them figure out whether or not it is a surprise
bill, and to make the plan hold them harmless, go through the
appeals processes, or complain to the regulator.
Mr. NEAL. Okay. Thank you, Mr. Chairman.
Chairman SMITH. I recognize the chairman of the Health
Subcommittee, Mr. Buchanan.
Mr. BUCHANAN. Thank you, Mr. Chairman. I want to thank all
our witnesses for being here today.
As a business guy for 30 years before I got here, I am just
looking at everybody talking about the backlog. It is
outrageous, especially when you are talking about cuts. You
send a bill in, you might not get paid for multiple years or
whatever that timeframe is. You know, obviously, it is just
shocking.
So, I don't know, is it--are there firms out there? Is this
frivolous lawsuits? Is it hedge funds? What is driving--Mr.
Bobeck, you mentioned the idea of 110,000 claims. I can't
imagine that. But the other gentleman over here mentioned it
would be 10 years before he might get paid. How do--nobody can
run a business like that, especially in the whole health care
field, where a lot of people feel like they are not getting
paid fairly to begin with. Compound this, you are out of
business for a lot of small firms, as we talked about earlier.
But what is your thought on this? What is driving this massive
amount of backlog?
Mr. BOBECK. Congressman, just as a brief note, there are 13
different IDREs, of which we are 1. Although FHAS has received
81,359----
Mr. BUCHANAN. But on year 1 there is 130,000 claims you are
managing?
Mr. BOBECK. We have received, since the inception of the
program, 81,359.
Mr. BUCHANAN. And you are one of how many firms?
Mr. BOBECK. There are 13 firms, overall.
Mr. BUCHANAN. What are you talking about, a million--you
know, millions of claims?
Mr. BOBECK. So, since the inception of the program--and the
CMS has not released the latest statistics since March, but it
is conceivable that by this point it is close to that--but for
FHAS, we don't have any backlog. The timeline to get a decision
out by law is 30 business days. We are doing it in only 23
calendar days. And the reason for that simply is we have a
large staff who is working around the clock to get these cases
out.
We have a sincere, humble understanding and responsibility
to know that how our cases--the arbitrations we make affect the
entirety of the provider and the payer system, as well as
patients. We understand that we need to make these decisions--
ultimately, in any decision we make there is somebody who is
normally upset. Somebody wins and somebody loses.
But ultimately, what we suggest is that people continue to
move forward with the process. We will continue to have no
backlog. We will continue to make decisions. Program rules
around it did ultimately--do create backlogs. As noted, the
program has been on hold since August 3, so----
Mr. BUCHANAN. But the backlog that has been created, how
long does it take to get paid under normal circumstances,
ideally, of the ones that are in the dispute area?
Mr. BOBECK. When a decision is made, as noted by Ms.
Thornton, the plan needs to make their payment within 30
calendar days. However, even before we get the case, most
likely two to three months has already passed by before we even
get the case. The parties going back and forth among payments,
trying to negotiate it on their own. So conceivably, the
process can take about possibly five to six months. And again,
that is why we make our standard when we receive a case that is
23 calendar days to get out, to get those payments moving
along.
Mr. BUCHANAN. Thank you.
Dr. Bleier, let me ask you, there was a point made on
behalf of the organization you are with or work for or
something that 52 percent of the payments are not made on time
or not made at all. Is that what you said?
Dr. BLEIER. I don't recall that specific number. But if you
are speaking to our experience with the IDR process, the
overwhelming majority of the cases--we have only--the IDR
process has effectively been unaccessible--inaccessible for us
for a number of different reasons I think everyone is already
aware of. Out of the 400-plus submissions, I think 20 have gone
through arbitration thus far. The rest have been unadjudicated,
haven't been----
Mr. Buchanan. And how long does it take to go through
arbitration in a case, normally?
Dr. BLEIER. You know, I--from our experience, I think there
is some statistics that say 90 percent of cases or 91 percent
of cases still haven't been adjudicated after 6 months. I have
seen some information along those lines. I don't have that
information in front of me.
But I can tell you this. The majority of cases that we have
won, the overwhelming majority of cases that we have won, we
have received zero payment from.
Mr. BUCHANAN. Yes, but the other side of that, the time,
the energy of your executives or employees through that whole
administrative process, is a nightmare and very costly. And
then you get paid, and it is not half of what you think it
should be. So it is challenging.
Are there any other outside factors that are creating this
environment in a negative way?
Dr. BLEIER. You know, I would imagine there are. You know,
the main issue is it is just inaccessible. And we have been put
into this position because, again, we have been kicked out of
network from payers that we were in-network with for years.
We don't want to access the IDR process, especially given
what is going on right now. We have no choice. And
unfortunately, despite that being our only recourse, it is a
bit of a false recourse for us right now because if we do enter
that, you know, it takes forever to potentially be adjudicated.
Number two, often times the--typically, the fees associated,
especially when they are $350 for the non-refundable fee let
alone the additional administrative fees that are part of this
IDR process, far exceed typically our bills in the first place.
So, if we enter the process, pay the $350 non-
administrative fee, and then win the case, and then not get
paid on top of----
Mr. BUCHANAN. Thank you. My time is up. I yield back.
Chairman SMITH. Mr. Doggett is recognized.
Mr. DOGGETT. Well, thank you very much.
Eight years ago, I introduced the very first surprise
billing legislation in the Congress, and I was inspired by
stories like the one Ms. Spicer referred to. In my case, a
Texas woman who did all the checking to be sure she was in
network,--and then some instrument was used, unknown to her, in
the course of the surgery and she got a huge bill for that
instrument, which was out-of-network, or the constituent in
Austin who got a $4,000 bill for a colonoscopy out of network.
It took another five years after the bill was first
introduced, a blitz from private equity companies urging us to
do nothing, and heavy lobbying before any legislation was
passed out of this committee or became law. The battle largely
became between health care providers and insurance companies,
with some justified claims on each side and some abuses on each
side that we produce this final piece of legislation.
And it should come, I suppose, as no surprise today that
whether the bill is adequately protecting consumers is not
being fully explored.
Ms. Thornton, you testified in the very first subcommittee
hearing we had about surprise billing in Congress. And I note
your testimony, confirmed by other consumer protection groups,
that consumers are being protected from about a million
surprise billings every month as a result of this legislation.
But today's hearing fails to explore the loopholes referred
to by Ms. Spicer and others of you, such as urgent care
centers, ground ambulances, some of the problems that developed
concerning pathology and lab tests and other areas, and I think
that is where the focus should be--is why aren't we providing
more comprehensive protection to consumers?
Consumers, of course, in a discussion like this, are not
the sole concern. This Congress has shown a consistent
inability to address the problem of soaring health care costs.
It gets talked about a lot. There is finger-pointing and trying
to blame one party or the other for those soaring costs. But
when it comes to really doing something about it, and that is
at stake here, Congress fails to act.
On the other hand, the notion that a private practice of
physicians can't be treated fairly is a legitimate concern. Ms.
Thornton, if I understood your testimony, the way the system is
now, with all the improvements that may be needed in the
system, it is the health care provider, are you saying, that
prevails 71 percent of the time?
Ms. THORNTON. Yes, that is according to data released by
CMS.
Mr. DOGGETT. So really, the question is whether there are
enough changes that are necessary in the way this law is being
implemented to increase it so that it is higher than 71
percent.
Ms. THORNTON. Yes, we would certainly love to see a more
balanced process.
The chairman mentioned the advanced explanation of benefits
earlier. We certainly think that that transparent process could
be a potential game-changer to make sure that consumers, when
they are scheduling services, can make sure that their
providers are in-network.
Mr. DOGGETT. One of my concerns is that so often the
conflict is not between a private medical practice of a small
group and a giant insurance company, but between private equity
and a giant insurance company. I noticed that about a third of
the complaints are coming from one Atlanta-based equity-backed
private staffing company. Do you have any sense as to why that
is happening?
Ms. THORNTON. Well, that is a really great question. I
think we need to go have a little flashback to why our--why you
all passed this law to begin with. At that point in time, there
were certain private equity-backed staffing firms that were
really using the threat of surprise medical billing to extract
really high, relative to Medicare reimbursement, rates from
health insurance providers, right? And that is the reason that
Congress really took bold action to pass the No Surprises Act.
Unfortunately, what we are seeing, and the data released by
CMS does bear this out--that we continue to see a really small
subset of providers really taking advantage and using that
arbitration process. You know, it is not the small mom-and-pop-
type of providers that are taking advantage of this. This is
large, very well-established private equity-backed firms.
Mr. DOGGETT. Well, I am concerned about the testimony of
all our witnesses, particularly some of the comments Mr.
Budzinski made about the cost this has. But it has to be a
balance, not a phony balanced billing, as occurred and produced
surprise billing in the past.
I think we can make some improvements, but the focus ought
to be on the consumer, first and foremost. Thank you very much.
Chairman SMITH. I recognize Mr. Smith from Nebraska.
Mr. SMITH of Nebraska. Thank you, Mr. Chairman.
Thank you, certainly, to our panel here today for sharing
your expertise and insight. It is--I think we have got many
great perspectives here to try to help us take what is
obviously a bipartisan, I think, achievement previously, and
look for ways to improve upon what the situation currently is.
It is disturbing to hear the various data points, and
certainly delays. And time is money, we know that. And the
disruption associated with lack of payment, I think, should
concern all of us. So I hope that we can take away, you know,
from this timely hearing some solutions.
Dr., or I am sorry, Ms. Spicer, thank you for your work
with Community--as a community health advocate. Have you
observed any patterns that would be disproportionate perhaps in
terms of underserved areas or rural areas impacted by the
shortcomings that currently exist?
Ms. SPICER. We have--in our program we have--some of our
agencies in the Community Health Advocates Program, they are--
serve communities in rural areas in upstate New York, and we
have seen problems across insurers for 20 years or more around
access to care in those rural communities. And so, yes, there
are--you know, there are still issues that are there and can--
will potentially be worse if networks shrink. They are already
very, very small in rural areas in New York.
Mr. SMITH of Nebraska. And so the difficulty of navigating
the whole process for those you know, from rural areas for
example, is there anything that stands out to you that we
should be especially mindful of?
Ms. SPICER. Just access to help. You know, in rural areas,
access to everything is a little bit less than in urban areas,
potentially. So access to help with them for them to--for those
patients to find in-network providers, understand what costs
they may be facing if they have to--if they are forced to go to
out-of-network providers, and access other options like low-
cost care and clinics.
Mr. SMITH of Nebraska. Okay, thank you.
Dr. Bleier, can you give us a little more detail about what
you have observed as unique challenges perhaps that rural
providers face when complying with the No Surprises
regulations?
Dr. BLEIER. Sure. So our overall payer mix is probably
about 15 percent in general self-pay, and probably about 30-ish
percent Medicaid. So about 42 to 45 percent self-pay and
Medicaid, both of which, you know--for self-pay, unfortunately,
you know, they are not able to essentially, you know, pay
anything. And Medicaid certainly reimburses at a much lower
rate than the cost of the care we are providing. And we have
roughly another 25 percent that are Medicare as well, which is
also relatively low. And then the rest are commercial.
And for those rural communities that already have a lack of
resources in the outpatient setting, often times these patients
can't get in to see their primary care physicians. They may not
have a specialist available. In addition, they have limited
resources to begin with. So they wait and wait and wait. And a
common thing that we see is these patients present to our
emergency departments with a true emergency in extremis, things
that could have been preventable to begin with.
And when the emergency medicine providers there are also
suffering under this law, you know, the law itself fully
supported in bipartisan fashion, but when the law is not being
regulated in the manner of the legislation itself, that puts
undue pressure on those groups because they can only spend what
they bring in on resources. And all of that money for a group
like ours that we receive in reimbursement goes directly back
to pay our providers and our staff that helps our providers.
So in a rural community, when they are already under-
resourced, we are the true safety net of those communities. And
if we don't--and we are not able to provide the staffing in
those rural EDs, when there is a crisis that rural community
will suffer, unfortunately. And it is heartbreaking, as a
physician, to have to see that. But, unfortunately, those are
the unintended consequences.
Mr. SMITH of Nebraska. All right. Thank you, I yield back.
Chairman SMITH. Mr. Thompson is recognized.
Mr. THOMPSON. Thank you, Mr. Chairman, and thank you to all
the witnesses for being here today.
As has been mentioned numerous times already this morning,
we passed this bipartisan legislation to protect our
constituents from surprise medical bills. It was needed. I
heard in my district offices, my Capitol offices, and probably
daily--that is not an exaggeration--from constituents who had
received surprise billing and were having difficulties with
this.
As Mr. Doggett pointed out correctly, this has been
something we have been working on for five years before we
passed the original bill, and I think it is important to
acknowledge that our goal of protecting our constituents was
met by the bill that we passed, for the most part, but there
are still challenges. And I agree with all the witnesses and my
colleagues that we need to figure out how to address those and
make this an even better bipartisan solution.
I would like to ask about something I have heard from
providers in my district, and that is that insurers are often
simply ignoring the timelines for dispute resolution that were
required by the law that we passed. And I think it is important
to be clear that when we pass a law requiring payers and
providers to go through a dispute resolution process, we intend
for the relevant parties to participate in that process, not
ignore it.
Mr. Budzinski, you alluded to this in your testimony. Could
you talk a little more broadly about the issue of payers
unwilling to participate promptly in the process, and how we as
Congress could address that?
Mr. BUDZINSKI. Thank you, Representative.
It is a fact that timelines are not being adhered to by
many parties. Providers are required to hit certain timelines,
to submit determination requests on a timely basis, and the
penalty for missing a deadline for filing a determination is
that that determination request is dead for a provider. End of
story. It is just gone.
With respect to other parties involved in missing
corresponding deadlines, that is no--that is not the case, and
we would be glad to provide further detailed evidence to you
and your staff about where insurance companies and IDR Entities
have missed their timing and still there is no result except an
increase in inventory of delayed results that we are seeing at
our Health System.
Mr. THOMPSON. Yes, I would like to see that data, if you
could provide that, please.
Mr. BUDZINSKI. We certainly will, sir.
Mr. THOMPSON. Thank you.
Ms. Spicer, you mentioned that insurance plans, at least in
some instances, fail to automatically hold patients harmless
for surprise bills. This is a fundamental problem. Holding
patients harmless was the central point of the law that we
passed and what all of us wanted to accomplish for our
constituents. What are some things that Congress can do to make
sure plans know their obligations and meet those obligations
under the No Surprises Act?
Ms. SPICER. Thank you for your question.
Yes, I have seen on--at Community Health Advocates, on our
help line, consumers call with classic surprise bills that
should be covered under the NSA, however, plans are not holding
consumers harmless for those surprise bills.
I would say that, you know, there is--health plans get
coding and information on when a claim is submitted, and should
know that claims fit certain criteria, and should be paying and
negotiating with a provider in a way that holds a--holds the
consumers harmless. This is done for--even before the NSA,
before New York surprise billing law in certain commercial
health insurance plans called HMOs. That is what our surprise
billing law in New York was modeled after, the protections that
HMO--some protections HMOs--consumers had already in place.
So I think it is--it should be kind of built into the
claims system that the health plans can see what kind of claim,
and whether the claim would be a surprise bill, and hold the
consumer harmless for that claim.
Mr. THOMPSON. Thank you. I yield back.
Mr. BUCHANAN [presiding]. Mr. Kelly, you are recognized.
Mr. KELLY. Thank you, Chairman, and thank you all for
coming.
So Mr. Buchanan and I are in the same business. We sell
cars. The biggest customer we have in our service department,
by the way, is the manufacturers. And we have--the health care
plan for the owner of the vehicle is their warranty. That is
also the biggest revenue stream we have coming into the store.
I can't imagine how you are running a business with the
accounts payable never being paid.
I have been in a personal situation where--and my wife will
get mad at me for this, but I think it is important for people
to understand this--we have a son who is a heroin addict, and
he was in a halfway house in LA. He passed out on a sidewalk.
Somebody called an ambulance. They took him to a hospital. I
kept wondering why he wasn't answering his phone, and the
reason why is he was in the hospital.
So eventually, within four days, he got out of the
hospital, and we had a chance to talk to him. And the reason I
bring this up is because, unless you have gone through it, you
can't understand it.
About two months later we got a bill for $260,000. And my
wife went absolutely--she says, ``Oh my God, what are we going
to do?''
I said, ``I will tell you what I am going to do. I am not
paying any attention to it at all,'' and it went away. I don't
know what happened.
And I don't know how you all absorb the accounts receivable
that you have on your books that you never receive. It is
absolutely incredible.
This invasive species, being government, has got its hands
into everything, and made it so difficult for normal businesses
to absolutely survive. I don't get it. I have been in business
all my life, and the two most important dates of every month
for me are the 6th and the 21st. And people say, ``Is that an
anniversary time?''; I say, ``No, that is payday.''
But we don't always see the revenue stream, so I can't
understand how can you possibly run the businesses you are in
when your biggest customer doesn't pay the bill?
And I talk about--we talk about wonderful things that we
are going to do legislatively, and that is all good. We can put
it out there. But following the model is incredible. I would
never take advice, by the way, from the company that was $33
trillion in debt. I would say there is probably not one of the
plans I want to follow. But you have--so complicated.
So you can't fix something with nothing. Now, Dr. Bleier,
you--in many ways--to a young man that grew up in Wisconsin and
then went to Pittsburgh. His name is Rocky Bleier. Is that
somebody that----
Dr. BLEIER. My grandfather would tell me that I was fourth
cousins.
Mr. KELLY. Okay.
Dr. BLEIER. I don't know if I have a----
Mr. KELLY. Yes.
Dr. BLEIER. I can't verify that.
Mr. KELLY. Well, you know, the fact that you take time out
of your life to come here today and try to help us understand
what we don't understand and how the policies that were well-
intended are actually not working and that your business model
is a business model that is totally unsustainable, I don't know
how rural hospitals exist anymore. It is incredible--when you
don't have the people on the shelf that could service the
patients that come in. And I think what they mostly rely on now
is just emergency care because they don't have people that can
handle more complicated issues, and there is just no people out
there to do that anymore.
If you could just give me a hint, just a little, what is it
that we could actually do?
It is nice that you came in here. It is nice that we are
talking back and forth, but I don't know. I still--if I was at
the dealership, the first thing I would look at every, every
day is our accounts receivable. And the ones--if they were over
90 days, write them off, they are not coming back. They are not
coming back to get anything from me, and we are never going to
see them again, but they walked away, you are on the hook for
what it is that they have done. We had to pay the mechanic that
did the work, and we have to pay the parts department for the
parts we put on.
So what is it that you can do? Because I will tell you
what, it is incredible today, the accounts receivable that we
are all trying to balance out. You are graced with the fact
that the government now is involved in it. So I--that is an
eye-roller. But what could we do? Just simply tell us what we
could do to help you.
Dr. BLEIER. I would say some different things.
Number one, you know, we are the safety net for the health
care community, you know, for the health care system across the
country. And we take care of patients under the most adverse
circumstances, when they are most vulnerable, as I am sorry to
hear about your experience, you know, from your family.
Mr. KELLY. Thanks.
Dr. BLEIER. But I think that, you know, some type of
reimbursement for unfunded care would go a long way to
providers who take care of those patients.
And I would say, with regards to the NSA, some enforcement,
enforcement that insurers are calculating the QPA correctly and
enforcement in teeth that they abide by the arbitrator's
decision and submit payments to providers or hospitals----
Mr. KELLY. Yes.
Dr. BLEIER [continuing]. When the ruling goes in that way,
because right now there is just no enforcement, even though it
is a great bipartisan piece of legislation. And that is--that
is my concern.
Mr. KELLY. Yes, my time is running out, but I got to tell
you, I don't know how you do it. I don't know how you write off
in your accounts receivable of things you never receive. It
becomes a taxable event for those that don't pay it, I think.
But we don't--and I don't think we enforce that. But I want to
thank you for everything you do. It is incredibly important,
what you do, and the fact that you face an unbelievable,
complicated business model. I don't know how you do it. God
bless you. Hey, thanks for coming in today.
Chairman SMITH [presiding]. Mr. Blumenauer is recognized.
Mr. BLUMENAUER. Thank you, Mr. Chairman.
And I must say, Mr. Kelly, I appreciate making it
personal--I know that is not easy, but it helps give the
committee a sense that there are human consequences.
Mr. KELLY. So, Mr. Blumenauer, you and I understand each
other, and Ranking Member Neal, the things that we go through
personally, I think we sit up here and somehow we don't
connect. And I say to people, yes, we do connect with you
because we go through the same thing. I wish we were the only
family that had that problem. It is incredible. And especially
mothers. They can't walk away from it. They just can't. And it
is really--all you do is just keep supporting them. And I think
that is what we do.
So I appreciate your comments. And I--my wife is going to
kill me for talking about this today, but I got to tell you,
until you actually go through it--you know how when you are
little, when you are growing up, and your parents would tell
you, don't touch the stove, it is hot? Everybody has to touch
the stove. You don't know it until you get burnt.
So it is good being with you, sir.
Mr. BLUMENAUER. Well, I appreciate the reminder that, in
the final analysis, we are talking about people, and there are
areas, regardless of our differences, that we can come
together.
This legislation was actually an example of coming
together. It has largely solved the problems. But we have heard
today from witnesses that it hasn't gone far enough, and there
are things that are head-scratching. And I appreciate the chair
and ranking member bringing this back before us, because we
ought to have a commitment to follow through on a good start.
We ought to do better. And I would think that there is a chance
to do that. And the witnesses have helped give me a better
sense of the shortfall.
Mr. Bleier, I mean, you explained that the majority of the
cases you won, there was zero payment, and that the bills are
often more than they are worth. Can you talk for a moment about
that dynamic, and what you think we could do to help you move
that forward?
Dr. BLEIER. Yes, I appreciate that.
You know, I think enforcement of the legislation would go a
long way. I think that a lot of groups are--like ours are
forced to enter the IDR process.
Mr. BLUMENAUER. Yes.
Dr. BLEIER. We have no choice. We have been kicked out of
network from contracts that have been standing for up to or
more than a decade with unchanged reimbursement rates. And,
because we are kicked out of network, we are forced to go
through the IDR process.
Right now, we have no leverage with the health insurance
companies. We can't--we want to go back into network. And
initially we received, for example, a 40 percent reduction. We,
a few months ago, went back to one insurer and said, hey, can
we go back in network? We had a 60 percent reduction.
So until there is enforcement and, you know, I think that
the insurers are forced to pay in--consistently with the
arbitration ruling, we will be at a disadvantage, and this
process will continue.
Mr. BLUMENAUER. And I would appreciate, if you have some
thoughts about ways that we can implement that, what you said
makes sense. I don't want to do it now, because my time is
almost up and I have another question, but your thoughts and
observations about what would make a difference for practices
like yours would be very useful.
Mr. Budzinski, you talked about large insurers who refuse
to negotiate. Could you elaborate on what you think we can do
to try and remedy that, to make sure that people are playing by
the rules, operating in good faith, and doing the roles that
have been assigned to them?
Mr. BUDZINKSI. Thank you, Representative. I think the
number-one framework of this phenomenon is that--the unintended
consequences of how the Act has been implemented is large
insurers no longer need to have emergency departments in
network in the counties where they sell insurance. They are
selling insurance in counties where they don't have any
emergency departments in network. How is that possible?
The reason is they don't have a need to have an in-network
emergency department. They don't have to negotiate with a
hospital or a health system or a physician group because they
can use the No Surprises Act process as it is currently being
implemented to pay in-network rates for out-of-network care.
And that has never been the case in the last 30--I have been in
the health care finance business for over 40 years. That has
never been the case.
Out-of-network care, because of its uniqueness, is always
reimbursed, historically, at greater than in-network rates
because, with in-network rates and discounts, there is always
an expectation of more volume, and therefore more discount.
With out-of-network care, all elective care is steered away
from you, and now you are left with only emergency care.
So I think that the solution to this is require that--under
the Act, that the initial payment being made by insurance
companies meets a minimum level that is consistent with
historical out-of-network payment for emergency services.
Mr. BLUMENAUER. Thank you, sir.
Chairman SMITH. Mr. Schweikert is recognized.
Mr. SCHWEIKERT. Thank you, Mr. Chairman. And Ranking Member
Neal and the chairman and many of us have been around from the
beginning of the debate and discussion on this, so I want to
walk through and make sure I am listening--sometimes something
I don't do well.
The discussion is almost--has two ends on this. Some of it
is the actual administering of the law, of the rules as it is,
how long it is taking the bureaucrats, the time, and some are--
maybe some of the game-playing has happened from the
Administration's rule-drafting and those things of what we
thought we were getting compared to how it has been drafted.
Setting that aside--and Mr. Bobeck, forgive the nature of
the question, but I am going to beg of you, be as brutally
honest with me as you can. If the rule set is saying, okay,
here are the rules, that this is an out-of-network--this is,
you know, what--the arbitration, why can't you and I just
automate that? Why can't we just write computer code that says
here is the market area, here is what it is, and here is--and
it is spit out?
Tell me where my--and it is not AI. That would actually
technically be even more an algorithm with constant updating of
the data. Why can't I completely automate this?
Mr. BOBECK. Congressman, thank you for the question. AI
relies upon one thing to do those algorithms, which is set
data. The data is not set in this particular case.
Our firm, since its inception, its founders, told us there
is a very important piece of technology that we have to rely
upon that has been helpful for us through this process, and it
is called the telephone. We have to continually talk with the
parties to make sure that they understand what are they dealing
with.
When parties want to submit a claim, many times the
provider doesn't even know which health plan that they are
trying to dispute. They are not even quite sure who they have
to tell that they would like to dispute. They are not quite
sure of the evidence they have to provide. And the same thing
on the payer perspective as well.
Mr. SCHWEIKERT. But Mr. Bobeck, in many ways, you are--and
I want to make sure we are not crossing each other, but that is
actually where automating it--check, check, put this in, check
this--I mean, the hyper-standardization. You could take away my
friend from Georgia's time problem and filing problem. It is--
and collapse the--actually, some of the cost, but also the
speed. Why can't we ultimately--because picking up the phone--
it is friendly, and you and I know how inaccurate a
conversation can be.
Mr. BOBECK. Thank you. Ultimately, since the program has
been involved for one year, parties are still getting to
understand the process.
But I will say this. Where parties provide the right
information, you are exactly right, the process goes much
faster. Processing decisions can be made in less than two
weeks, and that is frequently happening right now.
CMS, I cannot speak for them, but I do know that, through
the portal that they have created, they have continually made
improvements, and they have more improvements to make, which
will automate many parts of the process. They did not put that
out in the first model. The first model is simply to get it off
the ground.
But you are exactly right, that those are future
improvements that can be made, they will be made, and they will
make the process much more seamless and, I will say, very cost
effective for everybody.
Mr. SCHWEIKERT. Thank you, Mr. Bobeck.
Mr. Chairman, maybe as we start to have our discussions,
our bipartisan discussions on the side, the--finding out where
we do not believe the rule sets fit our vision, okay, fine,
that may require us to push some letters or do some statutory.
But what we should also maybe have an interesting discussion is
what would make this as seamless as possible. That if there is
going to be a dispute, it moves fast, quick, efficiently,
inexpensively. And that may be making it very clear that
technology can be the arbitrator.
And with that, I yield back.
Chairman SMITH. Mr. Pascrell is recognized.
Mr. PASCRELL. I thank the witnesses.
Surprise medical bills were once on the top of the list of
expenses Americans really do worry about. Whether it is an
emergency, an inpatient case, or inpatient care, Americans must
be protected. We came to that conclusion.
Despite the tired promises, insured patients keep facing
lawsuits, wage garnishments, garnishments for medical debt.
That is pretty gross. In fact, it may be outrageous. But it is
unacceptable.
So, in 2020, when committee Democrats enacted the
bipartisan No Surprises Act to protect patients, it was a law I
believe was carefully crafted to take patients out of payment
disputes. I remember back in that debate.
The Administration must implement the law as Congress
intended, no ifs, ands, or buts. Our law was designed not to
jeopardize patients and tilt the scales for industry.
Regulations that avoid these goals are not going to help the
patients. I don't think we are of like mind about that issue.
Patients need transparency provisions fully implemented, and
the law must be followed.
So, Dr. Bleier, yes or no, do health plans that fail to
follow binding dispute resolution decisions that collect
interest on money owed to physicians threaten physicians'
financial stability? Yes or no.
Dr. BLEIER. Yes.
Mr. PASCRELL. Dr. Bleier, yes or no, should there be a
financial penalty on an entity that fails to pay within the 30-
day required time period?
Dr. BLEIER. Yes.
Mr. PASCRELL. So, quickly explain how health insurers
issuing timely payments can help ensure patients retain access
to physicians. Give me a quick explanation, if you will.
Dr. BLEIER. If physician groups and emergency medicine
groups are reimbursed promptly, it allows them to have the
resources needed to take care of patients in any environment,
including rural environments, with less advantageous payer
mixes where perhaps they have a disproportionate number of
Medicaid and self-pay patients. And by increasing those
resources, I think the patients will get much better care.
Mr. PASCRELL. Dr. Bleier, in August of this year, the
courts stepped in to resolve guidance disputes for the
Independent Dispute Resolution that could have increased
administrative fees by 600 percent. Remember that. What is the
negative impact of higher administration fees, Dr. Bleier?
Dr. BLEIER. The higher administrative fees, both the non-
refundable and potentially refundable if you win, often times
greatly or significantly outsize the professional side or
provider side bill. So----
Mr. PASCRELL. And therefore?
Dr. BLEIER. And therefore, it precludes us from entering
the process.
And even if we win a dispute, we often times lose because
of the non-refundable portion of those fees.
Mr. PASCRELL. Does that make sense, Dr. Bleier?
Dr. BLEIER. I think--I hope so. Yes. Not always, but yes.
Mr. PASCRELL. And what is the impact of the higher patient
fee access? What is the impact?
Dr. BLEIER. From a patient perspective?
Mr. PASCRELL. Yes.
Dr. BLEIER. So again, you know, an independent group like
ours, we have no private equity backing. We have zero debt. If
reimbursement levels fall, and that is--can be through higher
expenses associated with fees, then we have fewer resources to
allocate towards what we really want to allocate our resources
towards: our providers taking care of patients at the bedside.
If we have less reimbursement coming in, we have less to staff
and provide those resources.
Mr. PASCRELL. How deeply is private equity involved in
this?
Dr. BLEIER. It is hard for me to say. In our experience we
have never had any equity backing, so I really can't speak to
that. We have been an independent group since 1992, so it is
hard for me to say, sorry.
Mr. PASCRELL. Mr. Chairman, thank you for your time.
Chairman SMITH. Thank you. Dr. Wenstrup is recognized.
Mr. WENSTRUP. Thank you, Mr. Chairman. I appreciate all the
input today from all the people on the panel and our members.
And I want to thank Chairman Smith and Ranking Member Neal for
having this hearing today.
You know, when we put together the No Surprises Act, we
worked with all of the doctors in Congress, Republican and
Democrat, who I might say, if I can, the real protectors of
patients in this world. And we considered patients first. We
wanted to alleviate their anxiety by taking them out of the
equation. I can tell you firsthand there are some times when
patients worry more about their bill than they do their
illness. And we wanted to take that anxiety away. It is very
important in the healing process.
We thought about providers who just want to help patients
but get reasonably paid for the work that they do, and go on to
see the next patient, and help the next one, and not spend a
lot of time in arbitration and other areas.
We thought about insurers. We wanted them to be able to pay
a reasonable fee so that they can stay in their ability to
insure those that they claim to protect, and that they will
have providers, especially quality providers.
We created a system that we believed would lead doctors to
want to be in-network and lead insurers to strive to have
doctors in-network, and provide their patients with a quality
panel, and a reimbursement to providers that was respectful of
the care that they rendered to the patients, and to fulfill the
promises made to the patients that they insure.
You know, I can remember once I had a patient in tears in
my office because she said, ``I chose this plan because they
listed you as a member.''
I said, ``We haven't been in it in three years.''
That was some of the motivation right there for getting
some of the changes made into this bill, that insurance
companies could no longer give false advertising, basically,
saying, ``This is our product,'' when it wasn't. That is what
was happening.
And we go through the process where a patient wants to know
what their elected procedure is going to cost. We ask the
insurance company, and they say, ``You have to perform the
procedure and then bill it first.'' Oh, that is a real doozy
for the patient that you claim to protect.
You know, Dr. Budzinski, you talked about out-of-network.
Out-of-network always paid more. Patients always had to pay
more out-of-network. They knew that, and they made that choice
willingly. Those were the rules. You have summed that up very
well.
And when--you know, here, when it looked like one committee
was going to go ahead and have a benchmark, well, what
happened? We have the documents. Insurance companies
immediately started sending notices out to doctors saying, ``We
are going to reduce your fees,'' because this was going to work
for them. Providers got the letters. We have got them.
Dr. Bleier, you talked about what is happening now because
of this. ``We are going to cut your fees, we are going to cut
your fees.''
I mean, in situations like we have now doctors quit taking
calls. I was in a large orthopedic group. You just say, ``We
can't afford it anymore,'' because--especially if they are out-
of-network. We know what is going on. And without doctors, what
is your product?
So why are we going towards this? And at a time when HHS
and other agencies, they get a cost of living increase, doctors
are getting paid less under Medicare. And all this just makes
it worse and worse and worse. And these are the ones that
actually provide the care.
I asked the rhetorical question, ``Who would have the
motives to change the clear intent of the law that we have
discussed today, and why? And what were the arguments that were
made? Who had the influence for these changes?'' It certainly
wasn't Congress, because we made it very clear.
I will submit for the record the three letters that we sent
to HHS before the rulemaking process, giving it--spelling out
the clear intent. We had a Zoom call with HHS, Labor, and
Treasury, spelling out the intent before the rulemaking
process. Bipartisan, we did this.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
And I might add that until Dr. Ruiz, who was on the call,
an emergency physician, until he spoke up, they wouldn't even
show their faces on the Zoom call. And he said, ``Would you
mind showing us who you are?''
And we asked who made the decision. Nobody could answer
that. Who was--who really made the decision? Who made the
argument?
I mean, Ms. Thornton, I would imagine, I would guess that,
in the comment and rulemaking process, that your organization
and others affiliated with you probably made comments to HHS
and others, right?
Well, my only question to you is would you mind sharing all
the communications that you had with HHS, Labor, and Treasury
concerning this topic? Would you mind sharing those with
Congress?
Ms. THORNTON. Yes, we are happy to have conversations with
your office about that.
Mr. WENSTRUP. Well, I would like to see your actual
communications that you sent. I appreciate that. Thank you.
Chairman SMITH. Thank you. Mr. Davis is recognized.
Mr. DAVIS. Thank you, Mr. Chairman, and thanks to all the
witnesses for a very serious discussion.
You know, when we passed the No Surprises Act into law, it
was designed to protect patients from predators, surprise
medical billing, establish a third-party mediation process
called Independent Dispute Resolution to determine the amount
of money doctors will receive for their health care services to
patients from insurance companies.
The problem is often profits versus greed.
The law uses an IDR process as a framework where payers and
providers negotiate and submit offers of what they believe is a
responsible, reasonable payment for medical services. And the
arbiter considers the qualifying payment amount, or OPA [sic],
to be paid to doctors. The arbiter, by law, is to consider a
range of factors, including a measure of median in-network
contracted rates for the health plan, the history of in-network
contracting with plan and provider, the complexity of the case,
and the education and skill of the physician. All these factors
are supposed to produce a fair compensation for the doctor.
Instead, the insurance companies are the ones that produce
the sole data used in this process without the consideration of
other pertinent factors that tend to deflate the rates to in-
network providers and narrow the number of doctors in-network.
We understand that the impact of these policies is causing
ripple effects through the health insurance market and
impacting physicians' ability to negotiate fair contracts with
insurers to be in-network because all contracts are now being
negotiated under the OPA [sic] ceiling, as plans know that this
amount is the most they will pay, whether the physician is in
or out of their network.
Dr. Bleier, how important is it that IDR Entities are
permitted the independence to look at all the allowable
information submitted by a party to support their offer, and
then make a determination of payment?
Dr. BLEIER. I think it is extremely important, and that is
why I think all--my understanding is all related physician
specialty groups and physicians supported the Texas Medical
Association's lawsuit against HHS to make sure that all of
those factors were considered, and undue emphasis wasn't solely
placed on the QPA when making those determinations.
Mr. DAVIS. And then let me ask you, what is the impact of
these policies on the stability of physician practices and, in
turn, patient access to physician services?
Dr. BLEIER. Unfortunately, the way the system is currently
operating, I think it is going to become debilitating if it
goes on too long. I think certainly I can speak for my group,
as an independent group that wants to go out into rural
communities and potentially provide our services in those
emergency departments--we already have four in those rural
communities, we are actually looking to potentially expand--I
think it is debilitating.
I think we simply will--our reimbursement and revenue will
be cut to such an extent we will have no recourse, if this
continues much longer, but to cut expenses. And our expenses
are provider staffing hours, our providers. So unfortunately, I
think it will have a harmful effect on our patients.
Mr. DAVIS. And finally, I understand that patient wait time
in emergency rooms is getting longer. Does this impact the
service?
Dr. BLEIER. Unfortunately, yes, there is an ongoing
boarding crisis across the country right now due to a number
of, I believe, workforce issues--is my understanding. But it
absolutely creates a difficult work environment for my fellow
colleagues in the emergency department and, more importantly, a
very difficult situation, I think, for our patients.
But as always, as emergency physicians, we do the best we
can, and we are resourceful with the limited resources that we
do have. So we still try to provide excellent care to every
patient, no matter what the conditions are.
Mr. DAVIS. Thank you very much, and I yield back, Mr.
Chairman.
Mrs. MILLER [presiding]. Thank you. I now recognize the
gentleman from Illinois, Mr. LaHood.
Mr. LaHOOD. Thank you, Chairman. I want to thank our
witnesses for your valuable testimony here today, and I am
pleased that this committee put this timely and important
hearing together today.
Understanding the cost of health care services in advance
empowers patients to make informed decisions for their
families, better manage their health care finances, and
advocate for fair and reasonable health care costs.
Like many of my colleagues, the cost of health care is one
of the top issues that I hear about from my constituents back
home in central and northwestern Illinois. Enacted in 2020 with
strong bipartisan support in Congress, the No Surprises Act,
which we have heard about today, has largely been a success in
providing certainty for patients when receiving care. Because
of this committee's bipartisan work and leadership, today
patients in every state across the country are better protected
from most surprise medical bills.
While this committee made great strides towards protecting
patients from costly and unnecessary out-of-network costs, we
have unfortunately seen agency officials bypass congressional
intent on surprise medical billing protections, which
ultimately harms patients' access to care. In rural counties in
my district, access and choice for health care services can be
a significant challenge. Flawed implementation of the No
Surprises Act has reduced patient access to care, which in--
particularly, has--which, in particular, has affected rural and
underserved areas.
As I visit with my rural health care providers, they
continually stress the fact that IDR process has been virtually
inaccessible for small practices, given their limited capital
availability, compared to many large and urban practices.
Hospitals and health care facilities should be focused on
delivering needed care and services, not worrying if IDR
billing process costs outweigh any benefits for patients and
providers.
The No Surprises Act was carefully drafted so as to not tip
the scales in favor of one party over the other, and my hope is
this committee and the executive branch can work to remedy this
imbalance.
My question for Mr. Bobeck and Ms. Thornton, in your
testimonies you both mentioned the need to look at the IDR
process and how reforms in this space would better allow
dispute filing and compliance with the No Surprises Act. Can
you both expand on what could be done by CMS to improve the
functionality of IDR process to streamline and to reduce
burdens on the parties?
Mr. Bobeck.
Mr. BOBECK. Congressman, thank you very much for the
question.
The first thing that can ultimately be done is regarding
the batching process. As many of the congressmembers know,
batching is a process by which different disputes can be put
together. Right now the process does not follow normally how
providers and payers bill each other. They usually bill in an
episode of care. Somebody comes in, there are various codes
associated with giving that care, and then they will be paid
upon that. That is not how the batching process works right
now.
CMS is currently undergoing the batching process and
changing those rules. Making those rules more in tune with how
people bill would be a very good step in the right direction.
Additionally, one of the biggest things that could be done
is ultimately the portal itself. With more implementation of
the portal, making more fields more clearly defined, parties
can provide better information. And the more information and
the better information they will provide, you will get a more
streamlined process that will have decisions happening at a
much more rapid rate.
From our perspective, we have run various algorithms on our
own end, and we can see very clearly that the better the data
that is put into the system, the better the outcomes that will
come out. Thank you.
Mr. LaHOOD. Thank you.
Ms. Thornton, do you have anything to add on that?
Ms. THORNTON. I 100 percent agree with whatever--everything
that he just said. I think technology can really help
streamline this process.
Mr. LaHOOD. Thank you. Those are all my questions.
Thank you, Madam Chair.
Mrs. MILLER. Thank you. I now recognize the lady from
California, Ms. Sanchez.
Ms. SANCHEZ. Gentlelady, please.
Mrs. MILLER. Sorry, gentlelady.
Ms. SANCHEZ. Thank you, Ms. Chairman. I appreciate the
opportunity to have this much-needed discussion on the historic
bipartisan progress that we made under the leadership of Mr.
Neal and Mr. Brady in passing the No Surprises Act back in
2020. And I am incredibly proud of the work that we did to help
patients struggling with unexpected out-of-pocket costs.
Since then, Democrats have worked tirelessly to narrow the
coverage gap for Americans. We passed the Inflation Reduction
Act and increased ACA subsidies to decrease out-of-pocket costs
for lower and middle-income working families. And, as a result,
we now see our nation has the lowest uninsured rate that we
have had to date.
And while the No Surprises Act is largely accomplishing its
goal in protecting patients and consumers from surprise medical
bills, many Americans are still saddled with high costs and,
sadly, very confusing provider networks. For those who are
struggling with high costs, this also means, unfortunately,
that they must take on medical debt. One in ten residents in
Los Angeles County, including many of my constituents, are
burdened with medical debt, and medical debt is one of the
largest sources of debt in collections, more than credit card
debt, more than utilities and car loans combined.
And it is not surprising that Latino, Black, and Native
American residents are disproportionately burdened by medical
debt, and many of these folks are insured. It is not that they
are not insured, they are insured. So, these networks still
need to deliver on the promises of the No Surprises Act. We
still have more work to do.
Now, Ms. Spicer, you mentioned that health insurance plans
and providers do not automatically hold patients harmless when
there are billing disputes. How long, on average, does it take
for you or one of your employees to help consumers resolve a
billing dispute?
Ms. SPICER. Thank you for your question. It depends on the
case. It depends on the capabilities of the consumer.
Sometimes, if you are going through cancer treatment, you
can't call me back for a month. So I don't know what your
notice says and what--how it relates to your bill and your EOB.
And I can't really help you until you are well enough to
communicate with me.
So, you know, and then other cases we can tell from a quick
call and an intake script, whether or not a bill is a surprise
bill and what to do about it. So it really just depends on the
case. But I would say, on average, anywhere from six weeks to
six months.
Ms. SANCHEZ. Six weeks to six months. And that is what the
help of someone who is very familiar with the insurance system.
Would it be fair to say that consumer assistance programs are
still under-utilized by many Americans?
Ms. SPICER. Yes, I think that is fair to say. We get, at
New York's Health Insurance Consumer Assistance Program--we get
8 to 10,000 calls a year. We are on the Explanation of Benefits
and the Adverse Determinations of Commercially Insured
Consumers, and recently last year added to the Adverse
Determinations of Medicaid-Managed Care Consumers. So we have
kind of a broader audience that is--those are state regulations
that require that notification to consumers. Otherwise, they
wouldn't know that we existed.
Ms. SANCHEZ. And so, what happens to the families and
patients who don't know to seek out the help that a consumer
assistance program provides?
Ms. SPICER. They would pay a bill, or they would not be
able to pay a bill and go into debt.
I got a client on our help line last week who received a
bill for an out-of-network lab, but not a corresponding EOB.
And if you don't have an EOB to explain that your bill was
denied as out-of-network but could be a surprise bill and
follow that process, and you are not held harmless by the plan,
and you are not savvy enough to know, you would pay.
Ms. SANCHEZ. Thank you. So, often times the people who are
least in a position to pay end up paying.
We have also seen provider networks grow narrower over the
past few years. Mr. Budzinski, have you seen the provider
network in your community change over the last few years?
Mr. BUDZINSKI. Yes, Representative. We do see, particularly
with the advent of the Health Insurance Exchanges, major
insurance companies in the country have decided that narrow
networks are an appropriate structure for Health Insurance
Exchanges. And many of the major insurance companies in this
country operate narrow networks in the service areas we serve.
Ms. SANCHEZ. Thank you.
And Ms. Thornton, how do narrow provider networks impact
the likelihood of a patient receiving a surprise bill?
Ms. THORNTON. Thank you for the question. I do think it is
really important to talk about affordability.
We all benefit when people can afford their health
insurance coverage. And to do that, our plans need to provide,
you know, high-quality networks of providers where they can go
and get care in a time of need.
To directly answer your question, all of our plans provide
provider directories that allow consumers to search. And
thankfully, the No Surprises Act included new provisions, new
consumer protections that, in the case that someone receives
inaccurate information, they are held harmless from that. So
that was a really important part of the No Surprises Act.
Ms. SANCHEZ. Thank you.
I want to thank all our witnesses for their testimony
today, and I yield back.
Mrs. MILLER. The gentlelady's time has expired. I now
recognize the gentleman from Georgia, Dr. Ferguson.
Sorry, Mr. Estes from Kansas.
Mr. ESTES. Well, thank you, Madam Chair, and I want to
thank you, all the witnesses, for joining us today on this very
important topic.
Mrs. MILLER. That goes off.
Mr. ESTES. It wasn't too long ago that the committee passed
meaningful, bipartisan legislation to address a very real
problem in the country around surprise medical billing. I am
sure all of us here have constituents who have been impacted by
surprise medical bills.
Erin in my district has told me about a nightmare she faced
after her husband was in the emergency room in Wichita. They
have insurance, thought they were doing the right thing by
going to an in-network hospital, only to find out that one of
the doctors who saw her husband in the emergency situation was
out-of-network, causing a massive surprise medical bill.
This is happening all too often in hospital rooms and
medical facilities across the country, and Republicans and
Democrats came together to stop it. The No Surprises Act was
designed to remove patients from the middle of the surprise
billing, empowering patients with up-front information for
scheduled procedures, protect patients when emergency services
were provided, and create a fair mediation process for
providers and the insurers.
This bill was the type of common-sense legislation that
folks like Erin and her husband needed. An emergency room visit
or scheduled procedure is stressful enough, but it can be even
more challenging if it is followed by an unexpected medical
bill from an out-of-network provider.
But today's hearing is a reminder of why Americans are so
frustrated with Washington. The unelected bureaucrats at CMS
have failed the American people by not complying with the
language in the bill we passed, and instead creating a dispute
resolution process that doesn't follow the spirit or
congressional intent of the law.
Even though elected lawmakers passed the bipartisan No
Surprises Act in 2020, the Kansans I represent continue to
suffer because unelected D.C. pencil-pushers are more concerned
with keeping the status quo than helping patients. The failure
in the D.C. swamp has led to fewer medical choices, longer wait
times, and higher costs for patients, while at the same time
has failed to deliver the transparency this body sought to
provide for those seeking medical care. Today we are calling on
CMS, that is entrenched in putting Washington first, to stop
slow-walking the implementation process and put patients first.
Mr. Budzinski, I have heard from many providers in my state
about the incredible wait times for not only the Independent
Dispute Resolution, IDR, process, but also for receiving
payment once the IDR process has been concluded. Can you please
tell me how many of these IDRs you have gone through, and how
many that have been paid for successfully?
Mr. BUDZINSKI. Yes, thank you, Representative. Of our 8,000
requests for determination at Wellstar, 588 have been resolved:
288, I believe, are in our favor and, unbelievably, only one-
third of those determinations in our favor have been paid by
insurance companies. And the deficiency is with some of the
largest insurance companies in this country.
Mr. ESTES. If that process or that approach continues
without some change, what does that mean for your business and,
more importantly, for the patients that you serve?
Mr. BUDZINSKI. As mentioned earlier, accounts receivable
that have never--that are never paid will impact our operations
in the long run. We are hopeful that there will be enforcement
of the timelines to remit payments to providers who have been
successful in getting favorable determinations from the IDREs.
Mr. ESTES. Well, thank you.
And Mr. Bobeck, I didn't really have a question for you,
but I did want to say thank you for raising the comment about
the IDR website being closed, that you can't add any more IDRs.
I mean, that is one of the things that we have identified by
law, this process that should be helping people, and we need to
make sure that it is highlighted that it is not being done. So
thank you for bringing that up as part of this hearing.
I just want to say, you know, the No Surprises Act
explicitly required that we have an Independent Dispute
Resolution process that should be concluded in a timely manner,
and payments should be paid no later than 30 days after the
final decision. These considerable wait times must be addressed
to ensure that our providers, especially those in rural areas,
can keep caring for the patients that need them most. That is
really what we want to focus on, is how do we make sure we
provide the right care for the right patients, which I think is
what all of you are focused on, as well.
So thank you, and I yield back.
Mrs. MILLER. Thank you, Mr. Estes. I now recognize the
gentleman from New York, Mr. Higgins.
Mr. HIGGINS. Thank you, Madam Chair.
Surprise billing is a weapon in our decades-long war
between players in the health care industry over who gets to
keep the fortunes generated each year from patients. What is at
stake here? According to the American Medical Association,
health care spending in the United States in 2021 was $4.3
trillion, or more than 18 percent of the U.S. economy.
You know, 30, 40 years ago, most health care providers were
not-for-profits. Businesses paid premiums. Patients typically
were confronted with pretty modest co-pays and deductions.
Those days are over. Health care has become big, big business.
So hospitals, doctors, and insurers are now in competition for
the health care dollar.
And then we have found even more egregious players in all
of this called private equity firms. The Kaiser Family
Foundation, an article called ``Sick Profit,'' or,
``Investigating Private Equity's Takeover of Health Care Across
Cities and Specialties''--that are highly profitable, private
equity spent nearly $1 trillion into nearly 8,000 health care
transactions in the past decade alone.
Private equities are not health care professionals. They
are moneymakers. In fact, according to Forbes, to doctors
private equity firms offer an alternative value proposition
promising to ease physician dissatisfaction with insurance
hassles. In exchange, physicians agree to relinquish
significant control of their practice to non-health care
professionals.
Ms. Spicer, you have some thoughts about patient
protections in this area, but it seems to me that what is
occurring here is Big Money's takeover of health care,
compromising the best interests economically and in terms of
health care of the patient.
Ms. SPICER. Thank you for your question. Yes, many times
consumers are left with the balance bill, and they are left
holding the bag. All of these transactions make it more
expensive in the end for consumers.
Mr. HIGGINS. Yes, and the surprise medical billing
legislation, it really is ineffective in addressing this issue.
Would you agree?
Ms. SPICER. I wouldn't say that the--all of the surprise
billing legislation is ineffective in addressing the issue.
I would say that if all the different provisions of the No
Surprises Act were implemented, if price--you know, the
transparency provisions move forward, patients would be able to
make more informed decisions regarding the care that they are
getting and to--and thereby, you know, avoid debt.
I think that, you know, the arbitration, the piece about
arbitration and the fees, depending upon the rate that is set,
it passes additional fees on to consumers. But I believe that
if the original intent of the law is followed, those--that debt
would not be passed on to consumers.
Mr. HIGGINS. Yes, it is undeniable that for a for-profit or
private equity that has taken over a medical practice: what is
their objective, and what is the leadership's objective? It is
to reduce expenses and to amplify profits. The only way that
you do that is to jack-up co-pays, jack-up deductibles, and
then, when someone goes to use the insurance they have already
paid too much for, there is very little underlying insurance.
And I am just concerned that Federal legislation can't stop
the trend that has begun in health care, and that is it is a
$4.3 trillion industry annually in America, 13,000 per capita
in America. And the profit motive is so strong that I am
concerned that legislation, while appearing to be helpful in
the margins, is not addressing the fundamental problem.
With that I will yield back.
Mrs. MILLER. Thank you, Mr. Higgins. I now recognize myself
for five minutes.
I would like to thank Ms. Chu for sitting in here for the
ranking member, and I would like to thank all of you for being
here today, taking your time to discuss with us such an
important issue.
Being from southern West Virginia, which is a very rural
district, my top priority is making sure that my constituents
have the best access they can to quality health care. In 2020 I
was absolutely thrilled that the House passed the No Surprises
Act to help patients all across the nation to deal with their
medical bills, especially in rural areas, because many patients
don't have much of a choice about where they receive their
care. And this policy was a huge win for patient-centered
health care.
So you can imagine my surprise when I learned just how
wrong the implementation of this bill has become. One concern I
have about the No Surprises Act's implementation is that
Congress was very clear that ground ambulance services were not
included in the NSA. However, I understand that some insurers
are telling customers that ground ambulance services are
subject to NSA.
I would like to note that the failure of CMS to issue a
clarification is creating real problems. Rural ground ambulance
services are particularly harmed because they are often small
companies or businesses with very limited resources, and many
are struggling just to keep their doors open. Reports that some
insurers are trying to force these rural providers to use the
time-consuming and expensive process when they aren't even
subject to it, nor do they have established qualified payment
amount, this is concerning to me, and I am dismayed that CMS
hasn't issued the written clarification that would solve this
confusion. And I hope that this is an issue that we will
continue to keep an eye upon.
Dr. Bleier, I would like to thank you for your hard work in
providing emergency medical care to rural patients. In rural
areas where access to care is so often limited, it is important
that patients who are seeking medical treatment--that they can
do it without the fear of a surprise medical bill.
One issue that we hear about time and time again is the
lack of staffing available in our health care workforce. In
rural areas it is becoming harder and harder to find physicians
that are willing to practice where their reimbursement rates
are so much lower. This is due to the coverage mix of their
patients.
Can you speak further about how compliance with the NSA, as
implemented by this Administration thus far, has contributed to
physician burnout in your workforce, and how this might
influence physicians looking to start their careers in rural
areas?
Dr. BLEIER. Yes, I appreciate the question. I think
physician burnout is very high among emergency physicians for a
wide range of reasons, you know, going back toward the COVID
pandemic. And emergency--I believe it is the highest burnout
right now out of any of the specialties, based upon some of the
recent polls that I have seen, unfortunately.
You know, it is a little bit of a moral hazard right now.
Our physicians will always want to do right by their patients,
and we try to do the best we can, and we are used to working
under very adverse circumstances. But due to a wide variety of
issues, including workforce-related issues, boarding, workplace
violence, these are all issues that emergency medicine
providers and other emergency medicine workers, nurses, et
cetera have to deal with in the emergency department.
From the emergency medicine physician and nurse
practitioner and PA perspective, when our resources for a group
like ours are fully debilitated--again, we were shocked when we
find out--found out--when this law was passed, this bipartisan
piece of legislation, we thought it was a great advancement. We
did not think we would be affected by it, because we had been
in-network with all the major payers in our region.
But then we were kicked out of network, and it is like
putting salt in a wound, quite frankly, for us. Because not
only are our providers working as hard as they can to do the
best they can under very adverse circumstances, but when on top
of that their reimbursement, their fair market reimbursement is
cut, it makes it very damaging to them. I think their psyche--I
think it puts us in a very difficult position.
And we want to do right by the patients, we want our
resources not going--having to go to an IDR process. We want
them to go towards our providers working in the emergency
department to provide the very best care they can in these
rural emergency departments or any emergency department we work
at.
Mrs. MILLER. Thank you. I yield back my time. I now
recognize Gentlewoman DelBene from the State of Washington.
Ms. DelBENE. Thank you, Madam Chair. Thank you to all our
witnesses for being with us today. I appreciate it.
Like many of my colleagues on this committee, I was proud
to pass the No Surprises Act into law to protect Americans from
unfair surprise medical bills. Prior to this bipartisan
legislation and similar state laws, including in Washington,
regular people and families were frequently at risk of being
hit with devastating surprise medical bills for emergency room
visits and other procedures that were completely out of the
patient's control.
And while we have made great progress, there is definitely
more to do. In particular, there is a critical gap in our
consumer protection framework, which is surprise bills for
ground ambulances. According to Washington State's Office of
the Insurance Commissioner, the vast majority of surprise
billing complaints are for ground ambulance services, which
were exempt from the No Surprises Act.
So, if someone with private insurance in my state has an
emergency and calls 911 and gets driven by an ambulance to the
hospital, they are not only on the hook for the co-pays and
cost sharing if they haven't met their deductible, but may also
have to pay a surprise bill of $500 on average. For non-
emergency ground ambulance services, that surprise bill could
go as high as $1,000.
And it is not just a problem in my state. The Urban
Institute's Health Policy Center has identified the lack of
protection against ground ambulance surprise bills as a major
issue for consumers across the country. And so, Ms. Spicer and
Ms. Thornton, how has surprise billing for ground ambulances
impacted people's willingness to seek care in emergencies and
other situations?
Ms. Spicer, you want to start?
Ms. SPICER. Thank you for your question. In my state, in
New York, ground ambulances are covered under our surprise
billing law, and were actually covered under the definition--in
the definition of emergencies. So many, many insured were
protected from out-of-network ground ambulance surprise bills
even before our surprise billing law.
But we still get a number of calls from consumers who are
federally insured, who have ground ambulance out-of-network
bills, and they can't afford them. It is hard for them to
afford, it is hard for them to understand why their plan isn't
paying, and it deters them from going to the emergency room and
getting care when they need to.
Ms. DelBENE. Ms. Thornton. Thank you.
Ms. THORNTON. Sure. And first it is important to
acknowledge that our member health plans want to have a robust
network of ground ambulance providers in their network, because
we all know when you least expect it that something that you
may need to take, you may need to need in an emergency or other
situation.
You know, it is important to recognize that Congress did
not include ground ambulances in the No Surprises Act, but we
do understand that the regulators are really taking active
input on that question, and really debating how--what
recommendations to make along that area. So we are actively
participating in those discussions, and look forward to next
steps on that.
Ms. DelBENE. Do you--do you think that surprise billing for
ground ambulance should be prevented, and we should do
something here in Congress on this?
Ms. THORNTON. You know, we do want to make sure that
patients are protected and held harmless.
One of the things that I would caution us in thinking about
is if the arbitration process is broken, like has been
discussed during this hearing, I would caution us as throwing
more, you know, cases at that process. So I think it would
require first fixing that process before we add more to it.
Ms. DelBENE. Thank you. We will continue to work with all
of you as we try to move forward on this.
Also, Dr. Bleier, as you know well, the widespread use of
prior authorization delays and discourages medical care for
millions of Americans that are entitled to care. That is why I
have led the effort in the House, alongside my colleague,
Congressman Kelly, and others to modernize and streamline this
very outdated practice. And we have legislation, Improving
Seniors Timely Access to Care Act, to increase accountability
and help Medicare Advantage enrollees get faster care by doing
crazy things like establishing electronic prior authorization
process, making sure people are responding to provider requests
faster and in real time, and requiring plans to report on the
extent of their prior authorization use and how often they are
denying requests.
When we talk about the challenges that providers are
facing, could you discuss the challenges you and your patients
have faced due to abuses of prior authorization, as well, and
why legislation is so important?
Dr. BLEIER. Yes, we--I haven't dealt necessarily with that
issue directly from my perspective in the emergency department,
but I think we have certainly all dealt with it indirectly,
where patients maybe go to a community provider, they are
evaluated by that community provider, that community physician
feels that that patient study is warranted and medically
necessary, but they are unable to do so. And then the patient
is referred to the emergency department because they are then
able to get the very necessary study in the physician's
perspective.
Ms. DelBENE. And we talk about doing a good job of helping
providers and patients, here is another area we need to
address.
Thank you, Madam Chair. I yield back.
Mrs. MILLER. Thank you, Ms. DelBene. I now recognize the
gentleman from Tennessee, Mr. Kustoff.
Mr. KUSTOFF. Thank you, Madam Chair, and thank you for the
witnesses for appearing today.
I know that a lot of you have talked about the--maybe the
common experiences that you have had, and the frustrations you
have had with the whole process.
I could, Dr. Bleier, with you--and if I can, I tried to
talk to as many providers as I could about all these issues,
and one thing that kept coming back was--and you have talked
about it, Mr. Budzinski, you have talked about it--is you go
through the process and you prevail, whatever that means, and
then you have got however long it takes for you to get paid.
And cash flow is an issue whether you are operating a medical
practice, or a hospital, or a retail store, or any business.
So, Dr. Bleier, I am going to turn it around, if I could,
to you. You know the framework. You know what has been
implemented. If you could wave a magic wand, what would you do
to fix it? How would it be fixed?
Dr. BLEIER. Well, I believe I will be speaking out of my
turn to some extent, but I would, I guess, hire a lot more
IDREs, a lot more arbitrators to quickly and efficiently handle
the backload--backlog of cases. There is a lot of cases in the
pipeline.
And then I would also put a lot of resources into
enforcement. I would want--I would like to see enforcement. I
think it would be beneficial to see enforcement that the QPA is
being calculated appropriately--without ghost rates, for
example, et cetera. Even with the judicial ruling, they sort of
set the framework stating that that shouldn't occur. But there
is no enforcement or transparency, currently, as far as I
understand.
And then certainly, some enforcement in making sure that
the arbitrator's rulings are carried out and payments are sent
to providers and hospitals appropriately. So I would say
enforcement, transparency are the big things.
And then to do something to efficiently work through the
backlog right now in the system.
Mr. KUSTOFF. I will come back to the backlog in a moment.
How would you enforce payment?
Dr. BLEIER. I would imagine there would have to be some
teeth in it. You know, a small--you know, a $350 non-refundable
arbitration fee for a group like mine is a lot. That is
probably not a lot for, you know, very large insurance
companies, given their size and their net profitability
quarterly, which is--dwarfs a small group like ours.
So I don't know what that price point would need to be in
order to enforce payment and then carrying out what the law
states they are supposed to do----
Mr. KUSTOFF. Right.
Dr. BLEIER [continuing]. But it would need to be
significant, I would imagine.
Mr. KUSTOFF. I think in your testimony or in your written
testimony you talked about--that the majority of your
submissions are $1,000--under $1,000, I think, is how you
characterized it.
Dr. BLEIER. Yes, that is correct. That is my understanding.
Mr. KUSTOFF. And do you know how many submissions, how many
claims you have submitted, your practice has submitted?
Dr. BLEIER. I believe we have submitted about 400 claims
because it just seemed like, you know, number-one, early on,
you know, despite what the bipartisan piece of legislation
stated, the regulations, I believe, stated that the QPA should
be the primary determinant. We knew we were going to lose those
cases, so we had those sorts of issues.
We also had the associated very high fees which excluded
us, the backlog, the fact that even when we did submit we
didn't receive payment. So all of those issues prevented us,
essentially, from accessing the system. We are hoping to moving
forward, but that has been our experience.
Mr. KUSTOFF. Thank you, Dr. Bleier.
Mr. Budzinski, in your written testimony--and I was going
to ask you about how you would solve it, but you talked about
how this law disincentivizes health networks. I think the way
you characterized it was from having robust networks. So if you
could wave a magic wand, what would you do to resolve issues
and fix it?
Mr. BUDZINSKI. Yes, thank you for your question,
Representative.
First and foremost, the framework is as follows, as we
understand it. The courts have found that the administrative
process has been tilted in payers' favor.
Number two, we have just discussed today the fact that 70
percent of the providers are found--the IDREs are finding in
favor, in favor of providers. So the deck is stacked toward the
payer in the process, and the providers are still winning 70
percent of the time.
Why is that? What is causing this? What is the root cause?
The root cause, I believe, is that the payers' initial payment
to providers is being found to be substantially below what is
necessary.
So the magic wand is to require administrative processes
that the initial payment from payers be consistent with the
historical practice of payment for out-of-network providers. If
that were the case, I believe these backlogs would disappear.
That is what I believe.
Mr. KUSTOFF. Thank you very much. I yield back my time.
Chairman SMITH [presiding]. Thank you. Mr. Steube is
recognized.
Mr. STEUBE. Thank you, Mr. Chairman.
Earlier this year HHS Secretary Becerra acknowledged before
this committee that there have been more claims than initially
estimated, and the arbitration process has been overwhelmed.
The Centers for Medicare and Medicaid Services have contracted
with 13 entities to arbitrate cases. All 13 have different
processes for arbitration, and CMS has not had a uniform or
concise action in implementing the law. The Department of
Health and Human Services has been very slow to roll out this
law, and it is the constitutional obligation of the executive
branch to carry out what Congress passes.
Ms. Thornton, I would like to start with you. I would like
to ask you a few questions about the bureaucratic failures at
CMS, and maybe help me understand the almost inexcusable
directives and inability to follow congressional intent with
how the No Surprises Act has been rolled out. How much of this
can be cleared up by congressional action, as opposed to CMS
issuing clearer guidance?
Ms. THORNTON. Right. Thank you for the question.
I do think, you know, it is important to recognize that
the--you all passed the No Surprises Act to make sure that
coverage was more affordable, and to really make sure that
patients were held harmless from one perspective, but also we
didn't do anything to drive up premiums. So I do think it is
really important, as CMS is putting out guidance and
regulations, that we are looking at the affordability impact.
You know, we have weighed in on all of these different
guidance and regulations. We do stress the importance of
ensuring a balanced process between providers and health
insurance plans to make sure that we are not using this process
a lot. Unfortunately, in how it is rolled out, there certainly
has been an over-reliance on the use of IDR, 14 times more than
was initially anticipated, and that has certainly been really
challenging, from our perspective.
Mr. STEUBE. Are there reforms that CMS can make today to
clean up the dispute resolution process?
Ms. THORNTON. Absolutely. I think it is really important to
focus on solutions.
You know, there has been a lot of talk with my co-panelists
here around payment and challenges with getting paid on time. I
think by rolling out more robust infrastructure and technology
to give us a clearer dashboard of all of these various claims
and where they are in the process would really go a long way to
mitigate any payment delays that any of the panelists are
experiencing.
Mr. STEUBE. Is there a variation across the 13 arbitration
firms handling the cases and how they process the claims?
Ms. THORNTON. Absolutely. We have seen a lot of really
challenging scenarios, you know, making decisions for claims
that were really Medicare claims and not subject to the No
Surprises Act, really wide variations in the decisions that are
coming out--the same provider, the same area, the same service,
but a drastically different decision coming out. And
definitely, we would recommend the regulator to do more to
ensure consistent processes among the different entities.
Mr. STEUBE. Wouldn't it bring more efficiencies if CMS
standard [sic] the processes across the board?
Ms. THORNTON. Absolutely.
Mr. STEUBE. Are there certain suggestions, other than what
you just mentioned, that you would suggest?
Ms. THORNTON. I think greater oversight and review of the
practices of those entities would be well received from us.
Mr. STEUBE. Mr. Bobeck, I have got a couple of questions
for you. What steps, if any, can Congress take to resolve the
dispute resolution process between the hospitals, doctors, and
insurers, while at the same time protecting consumers from the
balance--from balance bills?
Mr. BOBECK. Congressman, thank you for the question.
Number one, I believe that Congress continue to see the No
Surprises Act through. As noted, millions of consumers are not
getting surprise bills. That is a success story that has
happened, and that is a universal agreement across the entirety
of the spectrum.
When it comes to the payers and the providers, continue to
put the pressure and the onus on the parties, as well as the
government to put forth rules that will clearly allow them to
speak with each other, understand what exactly they are
disputing. And I assure you those claims will go faster and
smarter.
Again, in our group we don't have a backlog. We have never
had a backlog. Cases go out within the 30 days. And the more
information the parties can share with each other, the cleaner
their claims will be and more disputes will go out the door.
Mr. STEUBE. How accessible is it for you to get questions
answered by HHS?
Mr. BOBECK. It is a continuing conversation that we have to
have with the government upon various aspects of how they would
like the process to be implemented.
To be fair, and it has been noted, yes, IDREs do have to
make decisions based upon the best evidence that they are
provided. In certain cases there is not a uniform standard that
is published. But in guidance we are all instructed to move in
the same way. With that being said, yes, there can be some
small delineations among the IDREs of how to go about that
process.
Mr. STEUBE. And I will just--I have only got a couple of
seconds left here. Dr. Bleier, does it make sense for HHS to
charge a $350 administrative fee even to hear disputes that are
less than that amount of money, especially with x-ray and other
radiological services?
Dr. BLEIER. No, it doesn't.
Mr. STEUBE. Thank you. Thank you all for being here today.
I yield back.
Chairman SMITH. Ms. Chu is recognized.
Ms. CHU. I would like to thank all the witnesses for your
testimony today on this important issue.
Prior to the No Surprises Act becoming law, millions of
patients struggled with financially devastating surprise
medical bills. As this law continues to be implemented, it is
important that we build on the progress and continue to protect
patients from unexpected out-of-pocket costs, while also
promoting fairness and payment disputes between insurers and
providers, as the law intended.
Ms. Spicer, as you highlighted in your testimony, consumer
assistance programs like CSS New York have played an incredible
role in helping millions of Americans navigate all kinds of
health care concerns, from understanding how to use their
health insurance, resolving medical bills that are often
confusing and conflicting, appealing health plan decisions, and
disputing surprise medical bills.
Now, New York is fortunate in having your organization.
However, Congress has not appropriated funds for these programs
since 2010, leaving many states without this resource. Most
consumers who are eligible for CAP assistance are enrolled in
employer-sponsored plans. And the majority of these plans are
federally regulated. But CAPs that operate with no Federal
funding cannot manage this large scope of work.
So as patient confusion around health care continues to
grow, can you talk about the importance of increasing Federal
funding for Consumer Assistance Programs, and how CSS New York
and other programs could use this funding to help more patients
navigate surprise billing?
Ms. SPICER. Yes, thank you for your question.
Health insurance generally is incredibly complicated. We
have all, as insured, gotten a notice that we don't understand,
an EOB that doesn't make sense in terms of the care that we
received, a bill that we feel we shouldn't pay for a giant
package in the mail, or an online login that explains our
network directory or our summary of benefits, our plan
contracts that we have no idea what it says and don't even read
it.
And currently our state funds our program after we lost
Federal funding in 2010.
It is hugely important for people like you and me to get
help with their health insurance because, unfortunately, in
America you need a lawyer in order to properly access care
sometimes and get insurers to pay claims and get providers to
stop billing you.
Ms. CHU. So that Federal funding was important. Yes. And
also----
Ms. SPICER. Absolutely.
Ms. CHU [continuing]. You are in a unique position, being
in New York. I would like to ask about the differences you have
witnessed in terms of patient experiences in the time following
the enactment of New York's out-of-network surprise billing law
in 2014 and then after the enactment of the Federal No
Surprises Act. What changes have you observed in patient
dispute volumes, types of billing disputes, and other factors
between 2014 and now, before the No Surprises Act became law
and in the years following the law's enactment?
Ms. SPICER. Thank you for your question.
After the--before the passage of New York's surprise
billing law, we saw all sorts of out-of-network--classic out-
of-network billing cases that the NSA now covers, in-network
hospital, out-of-network radiologists, or out-of-network lab,
or out-of-network slew of services that were uncovered. After
our state law those classic cases were covered by the NSA.
And there were some things missing, including network
directory misinformation, which was the largest volume of calls
that we got after we passed our own law in New York State. The
second largest volume, of course, was federally insured
consumers who just had no protections.
And now, since the passage of the NSA, the volume is less,
but we still have many calls just about understanding what the
process is and whether there--the consumer--the bill that the
consumer is getting is a surprise bill, and how to cure, if it
is.
And then we still get many calls about ground ambulance for
federally-insured folks and other kind of follow-up to the ER.
You are not--if an ER doctor puts a stent in, you are not going
to get another doctor to take that stent out, so you have to
incur an out-of-network cost outside of the ER for that. So
there are some loopholes there.
Ms. CHU. So there is improvement that is needed. But there
was some improvement with the No Surprise Act bill.
Ms. SPICER. Absolutely, huge improvement. And also in
regards to air ambulance.
Ms. CHU. Okay, thank you.
Chairman SMITH. Dr. Murphy is recognized.
Mr. MURPHY. Thank you, Mr. Chairman, and I want to thank
the witnesses for showing up today.
It is really, I think, a very sad state that we passed a
very, very good law that had a lot of debate internally,
bipartisan support over here, bicameral support, signed into
law by a president, and then, when there was a new
administration that came in, decided--what was a balanced law
between providers and insurers--to pretty much put everything
in the insurers' pocket. It is an absolute disgrace.
And we have met with Secretary Becerra once, two, three
times, and the answer was it is always in court.
I absolutely applaud the Texas Medical Society for suing
against this, because what has happened is, yes, I think we all
have a consensus agreement that the No Surprise--or that
surprise billing was an absolute problem. Take it out of the
hands of the patients, absolute. But when you turn a process in
which is supposed to be equal and balanced, which was
absolutely done, and you turn it all over to insurance
companies, I am not sure what the Administration is trying to
prove, but this has become an absolute boondoggle for insurance
companies.
Mr. Speaker, I would like to ask unanimous consent to enter
into the record a letter from Blue Cross Blue Shield of North
Carolina to a physician practice stating that the interim final
rules--and this was probably two days after the interim rules
came out--provide enough clarity to warrant a significant
reduction in your contracted rate with Blue Cross Blue Shield.
In some instances, insurers, the next day after the rule
was proposed, cut fees 40 percent. Guys, we all know that
medicine is a business, sad enough, but there is no stability
in that when the insurance company is absolutely raping
(reaping?) profits off of the backs of those who provide the
care.
So with all--unanimous consent I ask that this be done.
Chairman SMITH. Without objection, so ordered.
[The information follows:]
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Mr. MURPHY. There was no teeth in the legislation, sadly
enough. Thirty-day rules once things were adjudicated. We are
going to get to some teeth in this, and the people who are
holding out the money may not like it, and I invite them to
come in my office and help us craft legislation.
Dr. Bleier, thank you for being in here. The statutory
language was very, very clear. The Administration chose not to
use it, and only to use the QPA as the primary consideration in
the IDR process, which insurance companies have deflated on the
dollar.
And by the way, they are not hurting. United, 20 billion--
with a B--in profits, while we have practices that are not
being paid for months, for months after they have been
adjudicated.
So, Dr. Bleier, what has your experience been with the QPAs
offered by the insurance companies?
Dr. BLEIER. Sometimes we don't know if we are being offered
a QPA. It is often times not listed on the initial payment. But
the QPAs can vary tremendously, and sometimes they don't really
make a whole lot of sense with the marketplace.
So, you know, our understanding in speaking to colleagues,
as well, is these QPAs are cited, and a lot of smaller groups--
and our own, for example--have even less bandwidth to deal with
that decrease in reimbursement, given their staffing models,
and often times are forced to come out of network. They are
kicked out of network due to a cited QPA that may or may not be
correctly calculated with no transparency to verify, and they
are forced back in-network at a substantially lower contracted
rate. And I think that has been a real issue for a lot of
groups, from what I hear.
Mr. MURPHY. It is a destruction of medicine, and I lay that
flat on the hands of our insurance companies.
You know, we have seen this with PBMs, the absolute
extortion that is going on with them. And it is all vertical
integration charged by our insurance companies.
According to a survey, 50,000 doctors, those who take care
of patients, said that 100 percent of providers have been
threatened with contract termination. What a way to treat your
clients. What a way to treat your clients. ``We are cutting
your prices, those of you who take care of the patients. We are
cutting your prices so our CEOs can earn millions and millions
of dollars.''
On average, 81 percent of providers had an average of nine
in-network--in-network--contracts terminated by payers, things
that were going fine until, all of a sudden, insurance
companies decided, well, we can take advantage of this. Payment
cuts up to 52 percent. Nearly 60 percent of payments won in
arbitration were not paid within the 30-day termination.
And I want to ask Ms. Sailer there, you said that it didn't
fit--holding back money did not fit your business model. Can
you explain what you mean by that?
Ms. THORNTON. Ms. Thornton? You meant me? Sorry.
Mr. MURPHY. Yes, I am sorry. Yes, yes, yes, yes.
Ms. THORNTON. Sure. You know, we really depend on having a
robust network of high-quality insurers. An employer is not
going to want to buy coverage that doesn't have a robust
network. So we need to have a collegial relationship with
providers.
So I think, with the goal of bringing more providers in-
network, it is not in our best interest to withhold payments.
Because eventually----
Mr. MURPHY. Yes, well, you just heard Dr. Bleier, where
basically people get bullied, kicked out of network to come in-
network at a much lower cost.
And you know, last I checked, patients' premiums have not
gone down, have not gone down. They have skyrocketed. And
insurance companies' profits have absolutely skyrocketed. The
folks in the middle are what is destroying American medicine.
The doctor-patient no longer--taking care of the patient, it is
the folks in the middle who are absolutely, absolutely
extorting money off of the American patient.
I will just say this, and I will close. I am going to work
on proposing legislation. Thirty days is fine, but when we put
no teeth in that bill, that is going to add one percent
compounded daily for insurance--to insurance companies who do
not pay their claims on time. And I am happy to work with you
all, but this is ridiculous. When you all don't pay claims
eight months, nine months out, are you just waiting for the
practices to go bankrupt? Because that is what is happening. I
am happy to work with you all, but I am moving forward with
this. Enough is enough is enough.
Thank you, Mr. Chairman. I will yield back.
Chairman SMITH. Ms. Tenney is recognized.
Ms. TENNEY. Thank you, Mr. Chairman and Ranking Member, and
thank you to the witnesses for your work and for the insight
that we have received here today.
It is hard to believe that just under three years ago we
came together in a bipartisan way, bicameral way to come up
with a No Surprises Act, groundbreaking legislation. And this
legislation, as we all know, is intended to finally hold
patients harmless for surprise medical bills and encourage
payers and providers to come up to create larger networks.
Since then, as we--you have heard pointed out by many, we
have had unelected bureaucrats really fail to comply with the
language intent of the law, and this has diminished the
achievement of the No Surprises Act.
And I just wanted to come up with a couple of--I have a
couple of different things I wanted to bring, just some
examples. And I wanted to cite one first, and then I want to
get into questions to each one of the witnesses.
So my first example is in May of this year an air ambulance
provider transported two twin infants from the same
transferring hospital to the same receiving hospital. Each
infant required its own ambulance, and each was delivered
safely to the receiving hospital. I am told the same insurer
provided the health insurance for each of these critically ill
twin infants. The situation was identical: two transports of
sibling infants with the same origin and the same destination
and the same ambulance service. Yet the insurer applied two
drastically different qualifying payment amounts, QPAs. One QPA
was nearly $13,000 more than the other for the base rate, and
greater than $100 more per mile traveled.
I am not sure who to direct this to, but I am thinking
maybe, Mr. Bobeck, you could explain to us. How is this
possible, that we have this completely identical circumstance
and the QPAs would be completely--would be--how can this be
appropriate and compliant with our regulations under law?
And maybe just give us a quick explanation, because I want
to ask Dr. Bleier about that, as well.
Mr. BOBECK. Thank you for the question. Respectfully, under
the rules we are not allowed to even determine the QPA. We are
only allowed to use the QPAs as given to us.
The IDRE's job is then to look at other evidence that would
support whether or not--that the payment made in this case was
correct or not. So respectfully, I would yield to the other
parties on this, as we can only make decisions based upon the
evidence that is presented to us in a particular case. Thank
you.
Ms. TENNEY. Thank you.
Dr. Bleier, how does this happen with this? How can we--how
do we fix this?
Dr. BLEIER. I----
Ms. TENNEY. It is a real injustice to our--to the people
that we are trying to serve.
Dr. BLEIER. Yes, it is a horrible set of circumstances. I
am sorry to hear. I have no explanation, because I also have no
transparency, you know, no view into how that QPA is
calculated. It is not----
Ms. TENNEY. How would we--maybe we could just pass this on.
How would we solve this problem, Ms. Spicer? I am going to
ask you the next question. Similar issues with dispute
resolution, but this is something that is really maybe a
failure on the part of our--of CMS and our enforcement. And as
Dr. Murphy alluded to and others, there is no teeth in this
legislation to make sure this doesn't happen.
I don't know if you would have a----
Ms. SPICER. It is--I would also defer to others on the
panel. I really--I am not privy to what information is
submitted with that--with those claims to come up with two
separate----
Ms. TENNEY. Let me--in reference--I have found it
interesting that you mentioned in your recent discussion with
one of my colleagues that you need a lawyer, basically, to deal
with some of these issues. And I recently had an organization
come to me with complaints that, despite the No Surprises Act,
some insurance companies are continuing to apply entire
balances to the patient's responsibility.
In one example, a family was billed for the full amount
after the insurance company denied their providers--again, an
infant situation, a neonatal critical care claim for their
underweight newborn. I mean, how often do we see these illegal
billing practices like this?
And if so, are you seeing any enforcement of it--referring
again to there is no teeth in this, we need lawyers. I mean, I
don't know if you----
Ms. SPICER. Yes. So in my experience--thank you for your
question. In my experience, the bill comes directly from the
provider to the family. The family doesn't understand why. And
so then what I do in my practice is to get the--put the plan on
the hook, make them aware that this bill is something that the
consumer should be held harmless for, and that it falls under
the No Surprises Act.
But if the consumer doesn't understand that there is even a
protection in existence that they can take advantage of, they
might pay that bill or go into debt for that bill. And then it
is about really fighting with the insurer to make sure that the
consumer is held harmless, filing grievances and complaints
with the regulator.
Ms. TENNEY. Thank you.
I don't know if I have time for another question, but Dr.
Bleier, in your testimony you outlined how some health
insurances are using the No Surprises Act to finally--
financially squeeze providers and, in some cases, drop them
entirely and instead depend on the No Surprises Act IDR
process. This leaves some patients with an insurance plan that
does not have a network provider in their area, the opposite of
the law's intended result.
And I believe I am out of time. You could either answer or
maybe answer us online in another forum, it is up to the
chairman. Just--I just want to--how does the lack of this local
network, you know----
Chairman SMITH. Respond briefly.
Ms. TENNEY. Yes.
Dr. BLEIER. Ironically, when there is not enough resources
in the community because of a narrow network, those patients
end up coming to the emergency department. We take care of
them. We take care of them no matter what. It is our duty, our
Hippocratic Oath. It is part of EMTALA. So it increases--it
drives the patients to the ED.
Ms. TENNEY. Thank you. My time is expired. I yield back.
Thanks so much to the witnesses.
Chairman SMITH. Ms. Moore is recognized.
Ms. MOORE of Wisconsin. Thank you so much, Mr. Chairman,
and I want to thank the witnesses for their patience.
I had a couple of questions that I wanted to ask. One of
the things that really wasn't clear to me--and maybe Ms.
Spicer, Mr. Budzinski, Mr. Bobeck, any of you might be able to
answer--is there a particular pattern which will characterize
those sort of claims that are disputed that fall through the
dispute resolution process?
You know, all of you talk about the thousands and ten of
thousands of transactions that come through. Is there a
particular medical practice? Is it OB-GYN? Is it baby care,
elder care? Is there a certain type of expenditure which might
inform some sort of repair of the dispute resolution process,
where you could start to say, ``This is where it seems to be
failing the most in terms of denials?''
Uh-oh. Wrong question, huh?
Ms. SPICER. Thank you for your question. I can say I
haven't seen a pattern in my practice, but we are--our state
doesn't use the same process for--before the NSA we had this
baseball arbitration process, and it was all kinds of claims.
And to echo what members of the panel had said, what I
would do in these sorts of scenarios was try to figure out
first if it was even worth it for the patient to do IDR.
Because if the patient was engaging in IDR, they would have to
pay the fee unless they won. And so was--you know, there is
kind of these baseline inquiries. Are you eligible? Does your
bill count towards the surprise billing law? And then does it
even make sense for you to file?
But I didn't necessarily--I would--people would get to me
when they had really big bills, like surgery, for example. That
is when you engage with a lawyer.
Mr. BOBECK. Congresswoman, thank you for the question. One
pattern that we have noticed clear throughout the process is
the more information that the parties have and that they share,
the better the process becomes.
In the beginning of this process, when people submitted
claims, only about 50 percent actually became eligible. That
number for us right now is closer to 87 percent of these cases
are eligible. And the ones that are not, that are determined
ineligible, that is mainly because of information they did not
have. If they are trying to put various claims together and
then they miss a certain key piece of information with it, that
claim will get kicked out. If they miss certain timelines that
they were not aware of, that case will get kicked out.
And as I also mentioned before, if they try to submit a
claim that is Medicare, something related to the VA or
Medicaid, those cases also would get kicked out.
These are cases of misunderstanding of the process. People
are getting better, and it is the one salient point we have
seen through this process. The more people share and understand
that information, the more seamless the process goes, and the
better it works for everybody.
Ms. MOORE of Wisconsin. So maybe this is to Mr. Bobeck or
someone else. You have talked about--and I think you, Ms.
Spicer, talked about in New York that you would have as many as
a million of these claims come through in a a month's or a
week's time. Is there a plan, once the portal is open again, to
do the huge backlog that will be there?
What do you anticipate in terms of the workload and the
workforce after the portal is reopened?
Mr. BOBECK. Congressman, from our perspective--and the
providers can certainly speak for themselves, and the payers,
on how they initiate claims--from our perspective, we have been
on hold now since August 3, 2023. We have a large staff that is
standing ready. They are training, they are going to do
everything possible to be ready, because we do know that there
is going to be a large tsunami of cases that will be coming
through that door.
For our staff, we have also made increased investments in
our technology on our own case management systems to more
seamlessly get through these cases whereby we will not have
that backlog, cases will move forward. But we also have to move
lockstep with the payers and providers because they are allowed
10 business days, or 2 weeks, to provide us their payments, to
use the system, and at the same time provide us their offers.
They are also going to need to be our partners in this in
making sure we get that information seamlessly.
But from our perspective, we have people ready, waiting,
and looking forward to starting this process sooner, because
that backlog of new cases will only get worse the more this
holds out. Thank you.
Ms. MOORE of Wisconsin. Anybody else with any? I got nine
whole seconds left.
Mr. Chairman, I yield back.
Chairman SMITH. Mrs. Fischbach is recognized.
Mrs. FISCHBACH. Thank you, Mr. Chair.
And I think Mr. Kustoff asked maybe the doctor a little bit
about, you know, if there is something Congress should do to
help enforce payments once they are settled. But I wanted to
ask Mr. Budzinski--I am sorry, I pronounce German names, but
not--and Mr. Bobeck about if they have some input on that.
Mr. BUDZINSKI. Yes, thank you. It is Budzinski, and I
appreciate your challenge.
With respect to what is the one root cause that is causing
all these disputes, I think there is no question about it. The
initial payment from the insurer to the provider is being set
by the insurer, and it is being proven that the insurer is
underpaying providers under the Act. And until that issue is
resolved in some way, shape, or form, the process is going to
continue to unfold, I believe, in a similar fashion.
Insurers no longer have a need to contract with emergency
departments of hospitals or emergency physician groups because
they can underpay, and it gets into this process, and then the
disputes blossom. And now we have backlogs like this.
So the initial payment should be established with a minimum
floor. That minimum floor should be consistent with out-of-
network historical practices for payment or, frankly, insurance
companies often have a secondary contract. They have a
secondary contract with a third party that providers often do,
as well. These are out-of-network service arrangements with
discounts to providers. Insurance companies are ignoring those
contracts, and they are simply paying the initial payment
amount under the Act without regard to their access to another
contract.
Mrs. FISCHBACH. Thank you very much.
Mr. Bobeck, do you have some input on that?
Mr. BOBECK. One thing we continue to repeat throughout this
is that, ultimately, the more the parties have experience and
expertise in submitting these claims, the better the process
becomes.
We don't believe the answer is having more IDREs, because,
ultimately, that would be bringing in more groups that don't
understand the system and how the rules are put forth. You need
groups who have the understanding and expertise to move forward
and get these claims paid and adjudicated in a timely manner.
That is where all of our people over the last year have spent
their time.
We are referees. We do not come up with the rules, but we
are the ones to enforce the rules, and that is ultimately the
process that we move forward on best. And we have noticed when
people understand the rules, it makes it a lot easier for us to
make the decision. Thank you.
Mrs. FISCHBACH. Do you think there is room for more
enforcement? Should Congress be acting on something?
Mr. BOBECK. One of the pleasures of being the referees is
we are not allowed to comment upon the rules. [Laughter.]
Mr. BOBECK. But we may not be able to define the strike
zone, but I assure you we will call the balls and strikes as
you give it to us. Thank you.
Mrs. FISCHBACH. Thank you very much, and you are very
diplomatic.
Voice. I can explain the sports references.
Mrs. FISCHBACH. Oh, he--my good friend is going to explain
the sports references to me.
But--and maybe what I should do is ask if there is anyone
else on the panel who would like to comment on that.
And I don't see any. Oh, here we go. Ms. Thornton.
Ms. THORNTON. I just wanted to respond to the question
that--or the comment that we are making artificially low
payments as our QPA. You know, the regulations have, and the--
your legislation had pages and pages of very detailed
information that we have to abide by when we calculate those
QPAs, which are based on actual contracts between providers and
plans. So I just wanted to emphasize that we are following
those regulations when we are calculating that, and we are
following it by the line.
Mrs. FISCHBACH. Okay, thank you.
Since I don't see any other volunteers, I will yield back,
Mr. Chair.
Chairman SMITH. Mr. Fitzpatrick is recognized.
Mr. FITZPATRICK. Thank you, Chairman. Thank you for holding
this hearing.
The No Surprises Act was signed into law, as we all know,
back on December 27, 2020 to protect patients against surprise
medical billing. However, the law has not been fully and
correctly implemented in the way that this Congress has
intended it to be. And as a result, patients are hurting in my
district and districts across America.
Emergency departments' wait times have more than doubled
since this law's passage in 2020. I personally have many
hospitals in my district that have reached out to our office
about the influx of people and increased wait times in their
emergency departments, resulting in overworked hospital staff
and patients, literally, being left in hallways.
Studies have suggested that 20 percent of emergency
department visits and 10 percent of elective inpatient care
stays involved at least one out-of-network provider.
I want to thank our witnesses for being here today to
provide us with your firsthand knowledge and your experiences
on how this law was implemented and is being carried out.
First to you, Ms. Spicer, the No Surprises Act, obviously,
was intended to give patients peace of mind that they would not
receive surprise medical bills weeks or months after what they
thought was a covered in-network service. Due to your
interfacing with patients every day, can you speak to what has
changed for patients since the enactment of the law, and what
outstanding concerns you continue to hear from patients today?
Ms. SPICER. Yes, thank you for your question.
What has changed for patients? They--obviously, in our
state, in New York, we had a surprise billing law before the
NSA. So what--I see the change is that now federally-regulated
consumers are protected from surprise and emergency service
bills.
What is outstanding for consumers is--which are complaints
that I normally get, are grounds ambulance, post-ER visits to
out-of-network doctors who provided the ER service.
And one of the things that we do most is just to counsel
people on what the law means for them, and how it can help
them, and how to engage in the process. When a mistake is made
and they are not held harmless, or when they receive a bill,
usually those two things go hand in hand.
Mr. FITZPATRICK. Mr. Budzinski, what is your perspective,
from the hospital standpoint, your concerns about
implementation, and what are some of the solutions you think
would address that?
Mr. BUDZINSKI. Thank you, Representative. I need to ask you
if you want the whole list, or just the top 10.
Mr. FITZPATRICK. You can start with the top several. How is
that?
Mr. BUDZINSKI. Very good.
Number one, as I said several times today, the reason there
are disputes is because the insurance company is in charge of
making the initial payment amount to providers. There is no
regulation that currently specifies what that amount needs to
be. There is confusion about that in some of the administrative
rules that have come out and that have been addressed through
other processes where the QPA might be the correct initial
payment amount, but there is no--it was not the intent of
Congress to establish that.
But unfortunately, we believe that the insurance companies
are now driving a big truck through that loophole and are
establishing initial payment rates that are very low, creating
disputes and that what we have heard today is that, when the
dispute is listened to by the independent person, the
independent entity, 70 percent of the time the providers are
right that they were under-paid. And this is when the deck has
been stacked against providers in the administrative rules.
So that is number one: initial payment amounts are being
set by an organization whose benefit is to set them as low as
possible. There needs to be a minimum established amount
consistent with what out-of-network payment rates used to be
prior to the legislation or, at a bare minimum, insurance
companies should be required to access all their contractual
agreements for specified discounts, and not ignore those
contracts.
In addition to that batching was mentioned earlier.
Batching needs to be revised, there is no question about that,
and the bundling of services. Hospitals in particular are
typically provide--paid on bundled arrangements. In an
inpatient setting, that is what is called a diagnosis-related
group case rate. Most of the time, in outpatient ER settings,
those are called ER case rates. In addition to that,
observation care that sometimes follows up on emergency care is
often reimbursed on a case rate. We believe that the bundling
of those types of things, consistent with how hospitals are
typically paid, is the right answer, as opposed to every line
on a bill having to be adjudicated through the process.
By the way, what that does, from a provider perspective, if
we can--if we send in one dispute for an ER service, an ER
visit, that is one administrative fee. If we have to go through
four or five or six CPT codes on an ER bill, each one of them
become, in effect, an administrative dispute with payment.
So batching administrative fee refinement, we believe that
the loser should pay all administrative fees, quite frankly.
Those are just the top few.
Mr. FITZPATRICK. Thank you, Mr. Budzinski.
Ms. Thornton, I was going to ask you about the insurance
perspective, but my time is over-expired.
So Mr. Chairman, I yield back. We will take that for the
record, that question. Thank you.
Chairman SMITH. Thank you. Mr. Beyer is recognized.
Mr. BEYER. Thank you, Mr. Chairman. Mr. Chairman, Ranking
Member Neal, thank you for holding this hearing. Incredibly
essential.
Mr. Budzinski, you just repeated something that was in Ms.
Thornton's testimony about 71 percent of the disputes that
reached determination favored the health care providers in the
area and suppliers. But you have also said that the law was
never intended to pick winners and losers, and that the health
insurance companies are winning overwhelmingly. Can you explain
the arbitrariness of the process, and how we can make it less
arbitrary?
Mr. BUDZINSKI. Yes, thank you, Congressman.
I am going to come back to the law was never intended to
pick winners and losers. But inside the framework the initial
payments paid by insurance companies are unregulated,
unspecified. And that process has created a situation where ER
physician groups, emergency rooms of hospitals are being
underpaid initially. And through that process, it only leads to
dispute. And so this----
Mr. BEYER. So let me follow up on that because Ms.
Thornton, again, said thatthey estimated 17,000 claims and said
they had 334,000. Are you suggesting that the insurance
companies, by intentionally under-paying, are creating an IDR
process? You know, creating the surprise billing complaint
appeal in the first place?
Mr. BUDZINSKI. That is the belief of our organization. Yes,
sir.
Mr. BEYER. Okay. Dr. Bleier, again, leveraging off Ms.
Thornton's testimony, she pointed out that there is only a
handful of companies, a handful of states that are filing all
these claims. You know, 60 percent of the claims from 5 states.
All the numbers are in her testimony. How do you respond to
that, that this is not just a handful of emergency room
practices that have figured out how to game the system?
Dr. BLEIER. It is hard for me to say what the intent of
anyone else's business is. I can tell you from our perspective,
and I suspect by extension a lot of other independent ER groups
as well, emergency medicine groups out there, I think the
number of arbitration cases--I believe you cited roughly over
300,000----
Mr. BEYER. Yes.
Dr. BLEIER [continuing]. Would be far, far higher if we
felt that the arbitration process was working more efficiently.
We have only submitted 400 claims, and it is largely
because the process hasn't worked up until now the way we would
like. And yet we have, you know, institutional damage, so to
speak, because the loss of revenue that we have experienced
because of those under-payments up front, we can't get that
back. There is no process. Unfortunately, with the Texas
Medical Association lawsuit rulings, they didn't allow for us
to submit claims, for example, at lower IDR fees going back to
the beginning of this year. That was not part of the ruling.
So--but I can't speak to why other groups are submitting
claims to the--you know, through the arbitration process.
Mr. BEYER. Okay.
Dr. BLEIER. But I can tell you our--that has been our
experience.
Mr. BEYER. Yes. Mr. Budzinski, Mr. Bobeck mentioned that
all they do is apply the QPA. They have nothing to do with it.
You complain in your testimony about the cloak of secrecy that
QPA has. Where does the QPA come from, and how transparent
should it be?
Mr. BUDZINSKI. Yes, so there is a couple of things.
First of all, we actually have had a number of our requests
for determinations with Mr. Bobeck's company. And let me just
say for the record their organization is one of the most
transparent and engaged IDR Entities that we have come in
contact with. So, from our perspective, we understand their
role as a referee, as an arbiter of the facts.
With respect to the QPA, the QPA is there, I believe, in
the legislation to protect the consumer. The QPA was not
established as the correct payment rate for a provider.
Now, I will tell you we don't really understand how QPAs
are calculated, nor do we ever receive calculations of what
QPAs are. But relative to payment to providers, it has not been
established that a QPA is the correct payment for providers.
And in fact, we believe in most situations that is not the
correct payment to providers, and our determination requests
reflect that.
Mr. BEYER. Okay, thank you.
Mr. Chair, I yield back.
Chairman SMITH. Mr. Moore is recognized.
Mr. MOORE of Utah. Thank you, Chairman, and I would like to
thank the chairman and the ranking member for holding this
hearing today.
We--let's take a quick moment of pause to just recognize
what we are doing. We passed something. It has created some
good for many patients, and we are now reflecting on it. We are
identifying the challenges of the implementation of it, and we
are trying to make improvements on it. Any time you give me a
chance to do that, I will be ready to do whatever work is
necessary. So thanks for moving the ball forward on this, and
for having us be able to discuss it today.
I am going to talk a little bit most mostly about the
Independent Dispute Resolution, so the IDR process, because
this implementation of this has not been without its
challenges, and there has been periodic pauses from this IDR
process, and it required that several regulations be rewritten
as agency officials strayed from congressional intent in
implementing the law.
So today I would like to focus on how this ever-changing
regulatory landscape creates a lack of clarity for parties
resolving claims in the IDR process. And so I would love to
hear from the witnesses on this particular issue, how has it
affected your operations.
Mr. Bobeck, as you note in your testimony, over the last
two years, as HHS, Treasury, and Labor have implemented
regulations for the No Surprises Act, the IDR process has
periodically been suspended. This prevents new cases from being
initiated through the Federal IDR portal, and prevents IDR
entities from adjudicating disputes between providers and
health plans. Can you speak to the operational challenges that
the--or stop-and-go implementation of this law has had,
particularly on IDR entities?
Mr. BOBECK. Congressman, thank you very much for the
question.
From the IDRE perspective, the biggest thing that happens
with the start-and-stop nature of the process is essentially
that you need to be able to staff up for a process that you are
never quite sure when it is going to begin again and then also
have a staff that is ready to handle a tsunami surge of cases
when it starts back up again.
So the biggest thing we have to look for in all of our
staff is, are you prepared for flexibility? And this process is
only going on for one year. So, if you were to look for experts
in the IDRE reprocess over one year, you will not find them.
Mr. MOORE of Utah. Right.
Mr. BOBECK. So the people that we have on staff, we need to
maintain them, even if they don't have anything to do. We are
maintaining them for their expertise and their knowledge. That
does create costs, obviously, for the IDREs as we move forward.
But as noted, again, this process is still in its infancy.
It is moving forward. We have seen the benefits of cases moving
through the system, payment determinations being made, and we
know that it is a great responsibility for our job to make sure
that all the parties, payers, and providers can have their job
done to help consumers. So we are ready to stand by, and
whatever challenges we face we feel are much smaller compared
to what the providers and the payers have to work through, and
then their patients.
Mr. MOORE of Utah. Backlogs. Can you speak to--a little bit
to the backlogs in particular?
You know, you have generally addressed it, you have talked
about a year timeline only. But specifically backlogs, how has
complying with this sort of changing regulatory landscape
affected that?
Mr. BOBECK. When it comes to the backlogs right now, when
the parties ultimately are going to start submitting all their
cases again, the timeline is still--for us, is still going to
be clear. The moment that we receive a case, we only have 30
business days to make an ultimate decision on it. When you have
an increased number of cases, it does put more impetus on
having a staff that is cost effective and streamlined, that
they will be able to handle that.
And again, we can only speak for ourselves. Yes, there are
other--12 other IDREs within this process, and ultimately some
of them are working through some of their older cases that they
have. But with that being said, for us the only thing you can
do is continually have a staff that is ready to move through
those cases because, for us, timelines are non-negotiable; you
have to do them.
Mr. MOORE of Utah. Dr. Bleier--and I would welcome comments
from Mr. Budzinski, as well--I have heard that small and
independent practices in Utah--I represent Utah--have
negatively impacted--they have been negatively impacted by the
IDR process, including from the dispute resolution backlog, as
I mentioned, and the 600 percent increase in IDR fees.
Well, these fees--this fee increase was reversed. Could you
speak to the operational challenges of this stop-and-go
implementation on provider practices as well as what financial
impact the IDR backlog has on providers?
Dr. BLEIER. For a relatively small group like ours, it
really cripples our operations to a significant extent. You
know, we don't have the bandwidth or capacity to--you know,
when we are receiving 70 percent less than our prior
longstanding in-network contracted rates, to submit a payment
for $350, $350, let alone $50, right?
And in addition to that, we have been effectively excluded
from the IDR process due to all of the things that we have
discussed today, right?
The--initially, the way that the QPA was given unfair
weighting, the backlog, the fact that even when we do submit
and win a case we are not reimbursed, so that really affects
our ability to provide the resources that we want and towards
effective provider and patient care at the bedside--I should
say patient care at the bedside by our providers.
Mr. MOORE of Utah. Any final comments? Maybe even has it
affected rural patients?
Dr. BLEIER. There is no question that when resources are
reduced, it is going to affect the capability of providers to
provide care in the communities they serve.
Mr. MOORE of Utah. Thank you. Thank you all. I appreciate
it.
Chairman SMITH. Ms. Van Duyne is recognized.
Ms. VAN DUYNE. Thank you very much, Mr. Chairman, and thank
you to our witnesses for coming to today's hearing.
In August, I was able to gather with health care leaders
from across Texas. And during this meeting I heard over and
over how unelected bureaucrats are failing to comply with the
No Surprises Act. And while this is not surprising, and
frustrating for everyone involved, it is the patients stuck in
the middle that are hurt the most.
And I am glad to see that we are holding this hearing, with
my state leading the most amount of disputes, and in Q4 of
2020, with a total of 25,277 disputes according to CMS reports,
further adding to the nearly 250,000 unresolved payment
disputes that are currently clogging the IDR backlog.
And, while I am also glad to see that my state's medical
association currently challenging in court--and I do want to
associate myself with my colleague, doctor and congressman Greg
Murphy, in his comments lauding TMS--it is--based on these
decisions, it is apparent that the CMS bureaucrats have elected
to go around the intent of Congress and make unilateral
decisions on what they think would be best, causing patients to
lose care and trust in their providers.
Every day that passes with the NSA and IDR portal that
remains closed, it pushes medical practices across America
closer and closer to insolvency. If the tri-departments keep
the portal closed for an extended period, potentially up to six
months, the consequences could be catastrophic. And such a
prolonged exposure could disrupt emergency medical services
disproportionately in the State of Texas, my state, putting
patients at risk and further straining the health care system.
And it is not just this committee that is dealing with
this. We are looking at CMS in--changing its intent, hurting a
number of private practices, small group practices, increasing
costs, decreasing quality of care. This is a problem, and we
need to figure out--there is a lot of solutions to it. Getting
this Administration to actually put forward those solutions and
getting CMS to actually do its job is another challenge.
But Mr. Bobeck, I really appreciate your comments dealing
with the IDR and some of the problems that they are facing
there. But, in your testimony, you talked about batching and
how that led to roughly 40,000 cases deemed ineligible due to
current batching rules. In your opinion, should CMS consider
revising the batching criteria to be more closely aligned with
what Congress intended?
Mr. BOBECK. Congresswoman, thank you for the question. On
particular with regards to batching, it doesn't totally
represent all the 40 cases--40,000 cases ineligible, but does
represent a substantial portion.
The feedback that we provided CMS ultimately when it comes
to episode of care and finding different ways to batch is
primarily what we hear from both the payers and providers which
more closely align to their billing practices. And we believe
the more in line you make practices, dispute resolution process
with billing, you will get better results, and the parties will
much more understand the process and they will come to much
more resolutions, as well.
Ms. VAN DUYNE. I appreciate that. When Congress drafted the
No Surprises Act, this committee was very specific about what
criteria should be used in IDR to settle the payment dispute.
And this is something back in my home state of Texas that the
Texas Medical Association has consistently advocated for.
My question, Mr. Bobeck, is before the IDR process was
halted, what criteria were used--were you using to determine a
case?
Mr. BOBECK. Congressman, do you mean before the Act's
implementation, or the new court cases as they were going
forward?
Ms. VAN DUYNE. The new court cases in which IDR actually
closed the portal.
Mr. BOBECK. From the beginning of the process, the Act
itself outlined very clearly the factors that had to be
represented, one of which was the QPA, and the number two was
what they called additional information. Additional information
included various aspects, one of which was previous contracted
rates over the last four years, the market share of both the
payer or the provider, patient acuity of how they presented in
a particular facility, the teaching status of that provider
facility, the level of training, and, obviously, as we already
mentioned, the QPA.
Initially, when it came out, the rules written by CMS
required that you look at the QPA first, as the first aspect of
it, and then you would look at the other factors to see if
there was some type of rebuttable presumption, if you will,
upon the QPA.
The court cases that came out in February made it very
clear to the arbitrators that you were to look at all of these
factors together equally. The weight that you give them is
ultimately up to the arbitrator in that particular aspect. And
so with those changes that come through the court cases, and
then obviously the CMS rules, we have adjusted how we have to
review those cases because that is the rules which we were
given.
Ms. VAN DUYNE. Dr. Bleier, real fast, would you say that
this weight on the median in-network rate represents the unique
circumstances of a case?
Dr. BLEIER. If you are asking me if I think the QPA should
be overweight, the answer is no.
Ms. VAN DUYNE. All right. Thank you very much.
Dr. BLEIER. Thank you.
Ms. VAN DUYNE. And I yield back.
Chairman SMITH. Mr. Kildee is recognized.
Mr. KILDEE. Thank you, Mr. Chairman, for recognizing me and
for holding this hearing. It is a very important subject.
I share the views expressed by some of my colleagues, and
my questions might be a little redundant. But as you can see,
we sort of come and go, and I may have missed some of the
answers.
But as the ranking member, Mr. Neal, said, we knew with
pretty good clarity what we were trying to produce when we put
together this legislation. And it is something that was a
bipartisan product, something that doesn't happen often enough
around here. And it is something that we, you know, take a
great deal of pride in. So it is a cause of a lot of
frustration for us to not see the legislation being implemented
consistent with what we know was, in fact, our legislative
intent and what we actually think the legislation does a pretty
good job of articulating. We want to see that adhered to.
But if I could pose a couple of questions, one to Dr.
Bleier and then another to Ms. Spicer, and you may have
answered this before, but if you could just elucidate me on
this subject a bit further.
One of the obviously challenging areas that we are seeing
with No Surprises Act is the rising reports of terminated in-
network contracts. And Dr. Bleier, you made mention of that. It
obviously is a problem in terms of contributing to the
challenges that we face in terms of trying to adjudicate these
disputes.
But it also would seem to me that it would have an effect
on overall health care costs generally. And I wonder if you
might comment on the extent to which you are seeing this, and
how it is playing out in the field.
And then, Ms. Spicer, more generally, I wonder if you have
suggestions as to what the Administration might do, or what
Congress may have to do to ensure that as we implement, we are
not seeing a narrowing of providers that really does create a
threat to patient care.
So, starting with Dr. Bleier, if you could comment, and
then Ms. Spicer.
Dr. BLEIER. Sure. You know, as I stated earlier, I
appreciate the question.
There wasn't--we didn't have an out-of-network issue before
the NSA. We were in network with all of the major carriers, and
that was always our strategy. We don't want to have patients in
the middle. We want to leave patients out of the middle during
their most vulnerable times in their lives and their family's
lives often times. And most of our contracts go back up to a
decade or more.
And we certainly didn't ask for any rate changes, despite
there being no inflationary clauses, despite the transfer of a
lot of responsibility to the patients as far as high deductible
plans go. And the insurers didn't ask for rate changes, either.
There was--most of those contracts were on evergreen, yearly
renewals, and they signed them without question, until the NSA.
Then the NSA comes out and, surprisingly enough, we really
didn't think we would be affected by this very reasonable,
well-crafted, bipartisan piece of legislation because we
weren't out of network with anyone. We weren't part of this,
you know, reported issue. But nonetheless, because of the NSA,
ironically, we have then been kicked out of network by a couple
of payers, and by a third payer as well, threatened, but
thankfully, you know, did not actually ended up kicking us out
of network.
Mr. KILDEE. So just out of curiosity, ostensibly, what is
the justification that is being offered for that, for taking
that step?
I mean, I understand what the reasoning might be behind the
wall, but what is offered as the justification?
Dr. BLEIER. There is no justification that I am aware of.
It is a, you know, 40 percent-plus reduction in reimbursement
if you want to stay in network.
Mr. KILDEE. Right.
Dr. BLEIER. And sometimes it is much less. And then, once
we are out of network, it is a 70 percent reduction in the
upfront payment. And then there is an IDR process which we
can't really access and take advantage of.
So it is an inherent--becomes a permanent loss of resources
for our group to use towards patient care.
Mr. KILDEE. Right. Ms. Spicer. Thank you, Doctor.
Ms. Spicer.
Ms. SPICER. Thank you for your question.
In New York State, we have state laws that require robust
provider networks. So I would suggest Federal laws are less
robust in that area. So I would suggest network adequacy
protections in the form--in that form.
And also, one thing that advocates in New York State bring
to our regulators often is surveillance of those networks.
Sometimes consumers complain of ghost networks. And, of course,
we still see misinformation regarding networks. And I would
advise surveillance of networks to ensure that the networks are
as robust as possible.
Mr. KILDEE. Thank you for that, and I want to thank the
panel for your contributions to this conversation.
I want to thank the chair for holding this hearing. It is
so rare that we come together. We should do more of this, we
should come together around a really difficult issue and find a
bipartisan solution. And it is my hope that folks down the
other end of the street are listening to this, and will work
with us to make sure that the law is being implemented in the
way it was intended.
With that, thank you, Mr. Chairman. I yield back.
Chairman SMITH. Thank you. Mr. Smucker is recognized.
Mr. SMUCKER. Thank you, Mr. Chairman, for yielding and for
holding this important hearing today. And I think, as Mr.
Kildee just said, you are hearing almost unanimously the view
of members of this committee and from both sides of the aisle.
This is an issue that--there was considerable work done
back in 2020. You know, we all want to ensure that our
constituents have access to quality health care, they have
access to the care that they need and at a price that they can
afford. We want them to understand the costs. And then we don't
want them to be surprised with large bills that they weren't
expecting. And so it is--we are all frustrated that this hasn't
been carried out in the way that was anticipated when this bill
was passed.
And I am--again, I don't know that I have a lot more to add
to this discussion other than what has already been discussed,
but I represent an area in southeastern Pennsylvania, the 11th
district in Pennsylvania, that has, you know, some large rural
areas. And I am concerned about care being accessible there,
and I am concerned about the impacts of this not being carried
out properly, and how that impacts us.
And I think, Dr. Bleier, you--I may ask you to expand on
this, although you have you have sort of just addressed the
question. But, you know, you have said, I think, 52 percent of
claims are not even paid. And you testified that there is not
even a clear mechanism right now to ensure that there is a way
to force that payment to come. So it has got to have an impact
on hospitals and providers' ability to carry out care.
And so, again, as I said, I am concerned that--the impact
this will have on patients who need to rely on your systems for
their care. So I don't know if you want to expand on that at
all. Have you had to alter or eliminate services? Do you know
of other providers who have had to do that because you are
being compensated at a slimmer margins than you should be,
otherwise?
Dr. BLEIER. I would hazard a guess that there are many
groups out there that have had to do that, but I can't say for
certain.
As far as our group goes, you know, we are really trying to
have a more medium sort of term view of this situation in the
sense that we have--although our revenue has been slashed
because of what has occurred, I think the owners of our group
who all work in our emergency departments every month have
taken the brunt of it. And we have tried to shield our nurse
practitioners and physicians' assistants and other providers
and administrative staff from that. But it can only go on for
so long.
And we are very hopeful, very hopeful, fingers crossed,
that these Texas Medical Association lawsuits will actually
bear fruit, that the regulation of this bipartisan piece of
legislation will be implemented consistent with the intent of
the law. And, if that happens, I am hopeful that, you know, we
will be able to continue to provide the level of resources that
we want to--all of our patients, including those, you know,
generally under-resourced communities within our state.
Having said that, though, if this continues, I don't see
any way we can continue the level of care that we currently are
providing. It absolutely will, for our group, lead to,
unfortunately, reduction in hours, staffing hours, potentially
reduction of positions entirely. It may even lead to us having
to withdraw, unfortunately, from certain contracts where, you
know, it is not sustainable. That undue pressure with that
razor-thin margin is just too much.
Mr. SMUCKER. So I think you have just articulated why this
issue is important and why it is important we get this resolved
as quickly as we can, why it should be implemented in the way
that was intended. This will affect--and potentially is already
affecting--individuals who need care who may not be able to
access care because this issue is being carried out in a far
different way than what was intended.
So with that, I yield back. Thank you, Mr. Chairman.
Chairman SMITH. Mr. Hern is recognized.
Mr. HERN. I thank the chairman and the ranking member for
hosting this bipartisan oversight hearing on surprise billing
legislation.
Almost three years ago, Congress passed the No Surprise Act
to protect patients from surprise medical bills. Before this
law you would hear stories of a patient being rushed to the
hospital for an emergency, and then surprised with an out-of-
network charge. With the passage of this law we are seeing the
private market work to negotiate claims and leave the patient
harmless.
I am proud I voted to support the No Surprises Act to end
balanced billing and root out fraud in the system. Today I want
to highlight another key provision in the No Surprise Act, the
Advanced Explanation of Benefit tool, or the AEOB. The AEOBs
are patient price estimator tools that empower consumers to
shop for their health services by letting patients know the
cost before--before--they get care.
This Congress is focusing on building out transparency
data. Still, until this information is personalized and
considers the patient's health insurance coverage, this data is
meaningless for everyday Americans. That is why it is so--why I
am so disappointed this Administration is dragging its feet to
implement the patient price estimator tools price required by
the No Surprises Act.
This committee has sent two bipartisan letters inquiring
into the continued delays in providing patients with these
tools. Mr. Chairman, I would like to insert for the record
these two letters from the Ways and Means Committee to HHS
inquiring about the delayed implementation of the AEOB.
Chairman Smith. Without objection.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. HERN. Thank you. Yet we have to get a clear answer
about when we will see full implementation of this provision.
Fortunately, innovators in my home state of Oklahoma are
working to ensure Americans can navigate the opaque health care
system. For example, Medefy Health in Oklahoma partners with
over 1,500 employers to provide approximately 300,000 members'
access to personalized cost estimates within the provider
selection process. Consistently, this tool delivers significant
health care cost savings to patients and the small business
owners administering their health insurance. It is an absolute
failure of this Administration to delay implementation of this
technology elsewhere.
Considering Americans' families' current economic
struggles, anything to help with financial planning should be a
priority. Knowing how much health services will cost removes
some anxiety patients face when seeking medical care. Patients
are nervous about their test results. There is no reason for
the added anxiety of not knowing how much a service will cost
them.
Ms. Spicer, in your testimony you mentioned the importance
of consumer protections and the shared story of a parent--a
patient who was not given an advance estimate of the cost of
this procedure. The patient received his explanation of
benefits from his insurance company after the procedure, and
therefore had no idea how much surgery--this surgery would cost
in advance.
Ms. Spicer, every day Americans shop for goods and services
and know the costs in advance. Can you speak to the positive
impact an Advanced Explanation of Benefits would have on
patients?
Ms. SPICER. Yes, thank you for your question.
The Advanced Explanation of Benefits is a--would be a
hugely positive tool for consumers to understand health care
costs associated with the services they want in advance of
getting those services. It would give them the ability to make
informed decisions, considering their bank accounts and their,
you know, other kinds of choices that they have in their health
care before they incur these crushing--potentially crushing
medical bills.
In one of the examples in my testimony, I talk about the
notice of consent waiver that is required for each--for--when
you go to a practice, each patient gets a notice of consent
waiver, and that will tell you if there is out-of-network
providers potentially involved in your care. But it doesn't end
that you may have out-of-network costs because of that, but it
doesn't give you any specifics about those costs.
It is also bundled with a bunch of papers that you sign
automatically, that you have to sign to walk through the door,
like the HIPAA release and the consent form, other consent
forms. So it really--what is in place now doesn't necessarily
give all that transparency and that information in order for
consumers to make an informed decision.
I would say that even the Advanced Explanation of Benefits
form, consumers are going to need help understanding what it is
because it is going to be complicated.
Mr. HERN. I thank the chairman and the ranking member for
working with us in a bipartisan way to make this happen.
There is nothing in America that consumers purchase that
they don't know what it is before the price of it, before they
pay for it, except for their health care. It is time for us to
get this resolved and fix this issue once and for all for the
American people.
Thank you, and I yield back.
Chairman SMITH. Mr. Evans is recognized.
Mr. EVANS. Thank you, Mr. Chairman. I want to thank the
Ranking Member Neal for all his work on surprise billing over
the years to help our constituents.
Providing access to price information is important to
Pennsylvania hospitals. In Pennsylvania, every hospital has a
patient advocate for financial counsel. The individual is
available to discuss pricing with everyone to clarify costs.
Ms. Spicer, in your experience, how helpful would it be for the
patients to have this kind of information to clarify costs when
they leave the hospital?
Is there other information that you think would be
important for hospitals to provide?
Ms. SPICER. Thank you for your question. Yes, it would be
very helpful for patients to have advocates to explain to them
costs. I think it would be even more helpful, as we discussed
today, to have them in advance of the hospitalization.
But certainly, in New York, we have a hospital financial
assistance law, and there are offices within that--the hospital
that are charged with extending that hospital financial
assistance and giving other information like patient advocates
offices. And we often at Community Health Advocates act as a
kind of intermediary and get information and share it out so
that consumers understand their rights, and also their
potential costs, and the costs that they have incurred, right?
We always get consumers who come to us to say, ``I don't
understand why the bill that I am receiving is so high. How
could the cost of XYZ be what is on this bill?'' Or the bill is
for, you know, thousands and thousands of dollars, but the
invoice doesn't tell me what is--what I received that they are
charging me for.
So, definitely, transparency in billing and pricing prior
to being billed is needed.
Mr. EVANS. Any thoughts you have in terms of implementing
incentives to make it happen?
Ms. SPICER. For the Advanced EOB, I can't speak to why it
hasn't been implemented. I think it would be great for
consumers, for--you know, for those pieces to roll out.
Mr. EVANS. I yield back. Thank you, Mr. Chairman.
Chairman SMITH. Mrs. Steel is recognized.
Mrs. STEEL. Thank you, Mr. Chairman.
Before Congress stepped in, a patient receiving emergency
care from an out-of-network provider or facility would receive
surprise medical bills. Seven in ten patients were unable to
afford their out-of-network medical bills, according to a
previous Kaiser Family Foundation survey.
Unfortunately, this scenario happened to John Hagee, who
survived a serious bicycle incident and had to visit an
emergency room care in Los Alamitos. He received a $5,000
medical bill for his visit and later discovered that the
hospital and physician group were both out of network. John,
like many others, had to face medical debt and significant
financial burdens due to receiving vital care.
The bipartisan No Surprise Act has been successful, but we
can all agree that its implementation has not, leading to
physician burnout and reduced patients' access to care.
I have heard from physicians across California,
particularly in emergency medicine, that issues with
implementation of the No Surprises Act have caused such
financial instability that many physicians are retiring early
and leaving medicine.
According to a local survey, 45 percent of California
physicians said they are considering retiring early. Three out
of four California physicians report patient challenges with
timely access to care. And 60 percent of California physicians
report difficulty staffing emergency on-call panels. Now
patients are being onboarded in emergency rooms, waiting for
specialists to become available.
To Dr. Bleier and Mr. Budzinski, since the recent court
rulings in Texas against the Administration's implementation of
the No Surprises Act, the Independent Dispute Resolution
process for resolving payment disputes were put on hold. Now in
this month the Administration has announced that it expects to
direct certified IDR Entities to resume issuing payments
determinations for some disputes very soon. This means that
providers are still treating patients without a mechanism to
get fairly paid.
For a provider, what does this freeze in the system do to
you and to your practice?
Dr. BLEIER. I appreciate the question. It puts us in a very
difficult situation.
You know, unfortunately, I think the insurers--and we all
know that we emergency medicine providers and staff working in
those emergency departments will take care to the highest level
any patient that presents to the emergency department, no
matter what, regardless of their ability to pay. We always do
the right thing for those patients.
However, we can only staff those emergency departments with
the resources that are available to us. So when our
reimbursement is slashed below market rates, longstanding
market rates in our area, and our revenue and resources are
dropped, we are not--and then we have no recourse--you know,
the No Surprises Act, this wonderful, bipartisan piece of
legislation set up this process by which we would have recourse
in that situation when suddenly a payer, where we had been in
network with them for a decade or more, suddenly slashes our
reimbursement by 40 to 70 percent, we would have this ability
to still advocate for ourselves and potentially still receive
fair payment.
But if we don't have--if our payments are reduced up front,
and then we have no recourse, inevitably what is going to
happen is we are not going to be able to staff those emergency
departments and put the resources in that those patients and
those communities need, which is most horrible for our patients
but, as you alluded to with some of your constituents, horrible
for the providers and nurses and other staff working in those
emergency departments who want to do what is right for those
patients.
Mrs. STEEL. Thank you, Dr. Bleier.
Mr. Budzinski.
Mr. BUDZINSKI. Yes. Thank you, Representative.
We are a large organization. But as I mentioned earlier
today, the amount of reimbursement that we have tied up with
the IDR process that is broken is over $40 million in under-
payments to our organization. And even an organization our
size, these are substantial amounts of funds that ultimately
require us to balance our budgets in some way, shape, or form.
And this ultimately missing revenue does impact our resource
allocation. There is no question about that.
Mrs. STEEL. Thank you very much.
Mr. Chairman, I have another question but my time is up, so
I am going to yield back. But I am going to ask for the
recording of my question.
Chairman SMITH. You can definitely submit the question in
writing----
Mrs. STEEL. Thank you.
Chairman SMITH [continuing]. And they will answer that.
Chairman SMITH. So----
Mrs. STEEL. Thank you.
Chairman SMITH. Thank you, Mrs. Steel. Mr. Feenstra is
recognized.
Mr. FEENSTRA. Thank you, Chairman and Ranking Member. Thank
you for the panel for being here today.
You know, we have challenges. We all see it. We understand
it. We know there are flaws. My question--I want to really
center around the batching. When you start looking at the
various departments, to batch claims to avoid the buildup and--
but the problem really becomes the implementation of the
batching.
So, Mr. Bobeck, in your testimony you mentioned about 75
percent of disputes were determined ineligible due to non-
compliance with the Administration's batching rules. Can you
describe the eligibility criteria for determining validity of
these claims?
I mean, what can be done here?
Mr. BOBECK. Congressman, thank you for the question.
Currently, right now, the eligibility is actually at 87
percent. So most of the cases are actually eligible. But of the
percentage of cases that are determined eligible, batching is
accurate as one of the reasons many cases are ineligible. And
it does not result from the parties not trying to give their
best efforts; it revolves around the parties trying to comply
with how batching has to be done.
So, for instance, most of the codes, service codes that
come through to an IDRE can be centered around 5 codes, 999281
through 999285. Those codes, you can batch those together when
they are the exact same service code, and they involve the
exact same health plan, the exact same provider, and also they
come within the same 30-day timeframe.
That just simply is not how providers and payers track
their claims. They don't track them over all of these different
patients. They track a patient's claim and all the ancillary
care that goes along with that. So it is a different mindset
that has been enacted under the rules, and therefore that is
what they have to comply with. And that is what they have to
spend a lot of their time just to get information to an IDRE.
And when we get that information, we can only say whether
or not that claim was done accurately or not, based upon what
was provided to us. So it provides not just challenges for the
IDREs, but, again, for the patient providers. And that is what
leads to ineligibility. It is not good faith efforts, it is
just simply an inability to track cases as they are accustomed
to, to be quite frank, over the last several decades.
Mr. FEENSTRA. So, Dr. Bleier, in what Bobeck just said,
what can we do to ensure that providers probably can use a
batching process in a meaningful way?
To me, there is merit here, but how can we get it done?
Dr. BLEIER. That might be a little bit above my pay grade.
[Laughter.]
Dr. BLEIER. I think simplifying processes, in general, is
beneficial. You know, I think sometimes in these regulatory
processes they can be uber-complicated and difficult for
providers to follow. Certainly, a lot of providers, you know,
will use revenue cycle management companies to submit a lot of
those payments. So, you know, the--batch those claims.
So it is a little bit outside my wheelhouse. But in
general, I think simplifying the process, making the process
more transparent on the submission side, I think, is always
generally----
Mr. FEENSTRA. Yes, I would agree. I mean, I think
transparency--and I just see all the red tape, all the issues.
I mean, I think we can make this simpler, and make it more
efficient.
Budzinski, similar. Can you describe what batching
procedures would help hospitals in their IDR processes?
I mean, what are some--I am trying to aim at solutions
here. That is what I am trying to do.
Mr. BUDZINSKI. We greatly appreciate that, Representative,
and thank you for the question.
So, as we said earlier, hospitals for emergency-type care
are typically paid on a case rate basis. Okay? Observation
care, post-emergency as a continuation is a case rate basis.
Inpatient care is a case rate. So that is how we are typically
reimbursed, not CPT code by CPT code by CPT code by CPT code.
So the current process, the current process is required. In
order to batch, you have to have the same exact CPT codes for
every single patient with the same payer, the same exact
identical care for every----
Mr. FEENSTRA. That doesn't happen very----
Mr. BUDZINSKI [continuing]. Every--it doesn't happen at
all. Every patient is different.
Mr. FEENSTRA. Yes.
Mr. BUDZINSKI. Every patient has unique needs. So what we
would be an advocate for is go back to a structure of batching
and bundling that is consistent with how hospitals are
reimbursed.
For example, emergency department visit, level one, level
two, level three, level four, level five. It is a case rate,
and that is how we are typically reimbursed. The CPT codes and
all the ingredients are not really relevant. It is about the
patient and the care, the level of care that patient is
receiving. That is an example. Observation case rates would be
another example.
Batching based upon how we are typically reimbursed would
be ideal, and that would simplify the process and, I think,
help--we think help reduce future backlogs by reducing the
number of----
Mr. FEENSTRA. That is right.
Mr. BUDZINSKI [continuing]. Of determination requests.
Mr. FEENSTRA. See, boom, we got a solution. We can do this.
I mean, it is not rocket science.
But thank you, and I yield back.
Chairman SMITH. Mr. Panetta is recognized.
Mr. PANETTA. Thank you, Mr. Chairman, I appreciate you
holding this hearing. And of course, thank you, Member Ranking
[sic] Neal, for all your work on this important issue.
And, ladies and gentleman, thank you for your patience and
your testimony and your information about the issues and
potential solutions for implementation of this very, very
impactful bill--at least we want it to be impactful.
I come from the central coast of California, in the 19th
congressional district. And when I am talking to my patients
there, the number-one thing that I hear about is access to
care. But I also talk to providers in my district. And the
number-one thing I hear about from them is payment issues.
Now, I think that we know the intent of the No Surprises
Act was to address a practice of balance billing that,
unfortunately, decimated families' finances and limited access
to care. But with the reports of a long and often arduous
arbitration process, it is clear that there is more work to be
done, as we are hearing today and, obviously, as you know. And
that is why we want to try to ensure that we are truly
improving access and, of course, lowering cost.
One of the lessons that I have learned in my limited time
in Congress is that we can do a real good job of passing
legislation, but we need the Federal Government to do an
excellent job when it comes to implementing that legislation.
And, unfortunately, today, as to what we have heard and what we
know, this is a good example of that not happening.
Now, a key component of an effective Independent Dispute
Resolution process is timely payment by the losing side. Under
the No Surprises Act, that payment is supposed to happen within
30 days. However, a recent survey by the Emergency Department
Practice Management Association found that 87 percent of payers
did not meet this requirement. And obviously, as you know, that
threatens the financial stability of already stretched
providers like the ones that I represent.
Dr. Bleier, in your testimony you mentioned the impact of
slow reimbursement by providers. How do these delayed payments
impact providers?
And if you could, I know my colleague mentioned benefits,
but how do you feel about the Administration penalizing parties
that don't pay within the required period?
Dr. BLEIER. Well, you know, it is a structural loss for us
the way that this has been rolled out, unfortunately. You know,
we--there is no way to claw back any of that revenue that we
have already lost, unfortunately.
As far as your comment on--or your question concerning
whether there should be some type of penalty, it--whatever will
ensure that, you know, the arbitrator rulings are followed in a
timely fashion, consistent with the legislation, certainly
seems reasonable to me.
We are expected to make our payments up front as far as
arbitration fees. We do that in timely. We are the ones where
the onus, despite receiving an upfront payment--again, 40 to 70
percent less than what we have historically gotten for years
and years and years--we are the ones where all the onus is on
us to make that submission, to complete the paperwork, to
complete the appropriate documentation. It seems only fair, I
would--from my point of view, certainly--to expect that the
other parties involved, as well, are held to a similar
standard.
Mr. PANETTA. Great. Thank you, Dr. Bleier, I appreciate
that.
Mr. Chairman, thank you again. I yield back.
Chairman SMITH. Ms. Malliotakis is recognized.
Ms. MALLIOTAKIS. Thank you very much. Thank you, Mr.
Chairman. Thank you to the witnesses.
The No Surprises Act was a major bipartisan achievement, as
was discussed from my colleagues on both sides of the aisle.
But, you know, the goal was to protect patients from receiving
these exorbitant bills from out-of-network care, often without
their knowledge and consent. And the establishment of the
Independent Dispute Resolution spearheaded by this committee
was designed to provide a fair mechanism for settling the
payment disputes between the providers and insurers.
However, as has been mentioned, in its implementation
unelected bureaucrats have gone against the congressional
intent and created a lopsided dispute resolution process which
favors health insurers over the medical providers. Medical
providers are now being forced to accept artificially low
payments, leading to reduced staffing and exacerbating rural
and underserved workforce shortages.
I am also continuing to hear from providers in my home
state of New York that--over the backlog of dispute resolution
claims waiting to be resolved. Recent surveys find that 91
percent of filed IDR claims remain open and unadjudicated.
CMS has recognized that the primary cause of delays in
processing disputes has been the complexity of determining
whether disputes are eligible for Federal IDR process. They
found that the health plan type was unknown upon dispute
initiation in more than half the disputes, causing certified
IDR entities to conduct additional outreach and further
delaying the eligibility review process.
I will start with Mr. Bobeck.
Do you believe that there is additional information that
could be provided that would help expedite this process and
help providers determine claim eligibility?
Mr. BOBECK. Thank you very much for the question. Yes is
the answer to your question.
During the open negotiation process, this follows the
process by which a provider has received a payment that they
disagree with. They have a 30-business-day open negotiation
process. What is supposed to be happening during that process
is the parties should be sharing that type of information.
As an example, you mentioned parties don't know which
health plan. If you are a TPA, let's say you are a TPA who
represents several health plans, self--many self-insured funds.
The provider themselves does not actually know who the health
plan is. They just see the TPA, they see a name, and then they
see other cases and they think that is all the same health
plan. It is not. There are different ones.
Parties are supposed to be sharing that type of information
throughout the process. And the more that they share that, the
more that they understand who they are dealing with, and then
those claims--we have seen it time and time again, it makes for
a much better IDRE process. You don't see delays in those
cases. You see timely and very quick adjudications.
Ms. MALLIOTAKIS. And what portion is the backlog attributed
to states like New York that have their own surprise billing
laws already in place?
And what is the current process for determining state or
Federal IDR eligibility?
Mr. BOBECK. When it comes to ultimately--right now, most of
the cases are coming from other states, as Texas. Texas, like
New York, also has its own surprise billing law, as well. But
that does not prevent cases still coming into the system that
are not captured by that state process.
When it comes to the backlog, again, we currently don't
have one, but there is one that has been newly created simply
by the portal not being open. And with the portal not being
open, providers and payers cannot resolve their disputes and
move forward.
Ultimately, when it comes down to the state process and
which state process applies, there are regulations, there are
rules to--which apply. But ultimately, those rules are not
always even clear to the parties. We always, again, have to say
that we are like a judge. We can only go on the evidence as
provided to us. The parties have to provide that evidence to
us, as well as what we can find about whether a state process
applies or not.
Ms. MALLIOTAKIS. Thank you.
Dr. Bleier, on that note, would including remark codes like
CARC or RARC help to ease the current backlog?
Dr. BLEIER. I think it would. I think anything, again, that
promotes transparency on the provider submission side would be
incredibly helpful.
Ms. MALLIOTAKIS. Okay. And Ms. Spicer, I understand you are
a constituent of mine from New York. It is great to have you
here. How has the experience been for patients in New York
navigating both the state and the Federal patient protections?
Ms. SPICER. So in New York we had our own system prior to
the NSA. I think we--it took a couple of years to get it off
the ground, and there are still issues with it. But I--
consumers in New York now that are--we have many, many
consumers in New York, especially in New York City, in the five
boroughs, that have self-insured plans. And they are--the NSA
applies to them specifically. They use those Federal processes
and they appeal if they are not held harmless for surprise
bills, and they are dealing with how to navigate those two at
once.
Ms. MALLIOTAKIS. So it is my understanding, based on the
whole conversation today, more transparency, more information,
being more forthcoming with whether these are state or Federal
would be helpful in the matter. And also contributing to the
high volume of claims moving through the IDR process is that
there hasn't been a meaningful, open negotiation period, which
is supposed to help address these out-of-network claims.
I thank you all for your time, and I look forward to
working with our committee to address these issues.
Chairman SMITH. Mr. Carey.
Mr. CAREY. Thank you, Mr. Chairman and Ranking Member Neal,
for bringing together--and all of you--for being here today and
going through this many hours of questioning. It has been
enlightening.
You know, the flawed implementation of the No Surprise Act
has created burdensome and often confusing guidance for health
care providers, including those that are in my home state of
Ohio. This is leading to patients facing longer wait times,
increased health care facility closures, and exacerbating
workforce shortages, ultimately reducing access for those in
the rural and underserved areas, particularly in my district.
Today we have heard from many of those providers who are
impacted, and see the harm caused by the poor implementation of
the No Surprise Act.
Dr. Bleier, my question for you, Congress created an open
negotiation, a 30-day period, for payers and providers to
settle the disputes before a third party would step in. How has
this open negotiation designed in the law worked for your
practice, or maybe not worked?
Dr. BLEIER. So my understanding and discussion with our
revenue cycle management company is that there has been
effectively no response on any of the submissions from the
insurers.
Mr. CAREY. Interesting. Okay.
Ms. Spicer, I want to compliment you on bringing up the
name of one of the people in your written testimony who was a
concert pianist and who had also--we had some time, I Googled
her, and I would ask all my colleagues to do the same. She is
very talented. But it really shows you the face of what happens
to people that, really, you would think something like that
would not happen to.
I just have a couple of questions. I have one question for
you. But the No Surprise Act was signed into law in late 2020
to give patients the peace of mind that they won't receive a
surprise medical bill weeks or months after they thought they
were covered in a network service. Since the enactment--and I--
some of my colleagues have asked this in a roundabout way, but
since its enactment almost three years ago, how have patients
benefited from this law?
Ms. SPICER. Thank you for your question.
Patients like Claudia have benefited hugely in being
protected from out-of-network bills that--our New York State
law would not have protected Claudia, did not protect Claudia
because it was based on network directory misinformation. She
received her $35,000 bill, and the NSA does protect consumers
against network directory misinformation.
Also, you know, thousands and thousands of consumers are
held harmless for out-of-network emergency service bills as a
result of the NSA.
Mr. CAREY. So do you have any--
Ms. SPICER. And air ambulance bills are also----
Mr. CAREY. Yes.
Ms. SPICER [continuing]. An inclusion that New York's law
did not have.
Mr. CAREY. So do you have any concerns that patient access
to care, which is already in jeopardy due to the health care
workforce challenges that we face, will be diminished due to
the implementation of this law at all?
Ms. SPICER. At Community Health Advocates we see access to
care issues every day. We have--I have, in my career of 24
years, I have always had clients who call me and say, ``I
can't--I want--I don't--I can't find a provider in my network''
that does a certain thing. So I--it seems that if this process,
the arbitration process, isn't fixed, that that could be a
result.
Mr. CAREY. Okay. And thank you again. Thank you to the
witnesses.
And Mr. Chairman, I yield back.
Chairman SMITH. I would like to thank our witnesses for
appearing here today. I appreciate your testimony and your
several hours of endurement.
Please be advised that members have two weeks to submit
written questions to be answered later in writing. Those
questions and your answers will be made part of the formal
hearing record.
With that, the committee stands adjourned.
[Whereupon, at 1:56 p.m., the committee was adjourned.]
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