Legislation for Surprise Billing May Decrease In-Network Reimbursement

Reston, VA – A new Harvey L. Neiman Health Policy Institute study, published in Radiology, reviewed the implications of unexpected out-of-network balance billing—commonly called surprise billing—on reimbursement for hospital-based specialties such as radiology. The analysis concluded that even physicians who never engaged in such billing practices may still be impacted by the No Surprises Act, which is due to take effect in 2022.

“The term surprise billing itself is a misnomer, since it is really a surprise gap in insurance coverage,” says first author Rich Heller, Associate Chief Medical Officer: Communications & Health Policy; National Director of Pediatric Radiology at Radiology Partners. The recently passed law, the No Surprises Act, includes protection for “Certain services (like radiology) and care provided by out-of-network clinicians at in-network facilities without the patient’s prior informed consent.” An example is an imaging scan taken at an in-network emergency department but read by an out-of-network radiologist without the patient’s knowledge or control. Prior to the Act, the patient may have been responsible for the difference (balance billing) between what the insurer pays and the physician’s out-of-network charge.

“Ending the problem of surprise billing is patient-centric, patient protective and non-controversial,” says Ed Gaines, attorney. “There is little disagreement that privately insured patients who, through no fault of their own, receive unexpected out-of-network care should be removed from insurer/physician reimbursement disputes.” However, the Act’s provisions and associated rulemaking may have unintended implications, including the potential for manipulation of rates for in-network services, which may impact patients’ access to care.

“Benchmarking, preferred by insurers, caps out-of-network reimbursement at the median of in-network rates. This favors insurers by giving them leverage over physician practices.” says senior author Richard Duszak, MD, FACR, professor and vice chair for health policy and practice in the department of radiology and imaging sciences at Emory University and senior affiliate research fellow at the Neiman Institute. “In contrast, third-party arbitration to resolve payment disputes between insurers and out-of-network providers preserves good faith negotiations.”  The impact of the No Surprises Act will depend on the rulemaking established by the government to implement the law with implications that may extend to radiology practices that are in network or have not been involved in out-of-network balance billing.  Even medical practices that are 100% in-network, 100% physician-owned, never practiced surprise billing, and acted in good faith could be negatively impacted.

To obtain a copy of the study or to arrange an interview with a Neiman Institute spokesperson, contact Nichole Gay at (703) 648-1665 or [email protected]. 

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About the Harvey L. Neiman Health Policy Institute

The Harvey L. Neiman Health Policy Institute is one of the nation’s leading medical imaging socioeconomic research organizations. The Neiman Institute studies the role and value of radiology and radiologists in evolving health care delivery and payment systems and the impact of medical imaging on the cost, quality, safety and efficiency of health care. Visit us at www.neimanhpi.org and follow us on Twitter, LinkedIn and Facebook.