The No Surprises Act was passed by Congress to protect consumers from surprise medical bills, which come unexpectedly and often with high price tags. What's really in the legislation? And how will it affect patients, hospitals and insurers? Lisa McDonnel of UnitedHealthcare and Michael Wentzien of Naviguard visited the Weekly Dose to explain.
One of the most important pieces of health care legislation was signed into law last December. The No Surprises Act was designed to protect consumers from surprise medical bills, those medical bills that come unexpectedly and often with high price tags. But heading into 2022, hospitals and insurers are still trying to determine how to implement the legislation's requirements. So what's at stake with the legislation? And how does it affect patients, hospitals and insurers? Lisa McDonnel of UnitedHealthcare and Michael Wentzien of Naviguard explain in this week's episode.
SPEAKERS
Michael Wentzien, Lisa McDonnel, Ira Apfel
Ira Apfel00:05
Hello, and welcome to UnitedHealth Group’s Weekly Dose Podcast where we'll get you up to speed on the latest trends, shaping the future of healthcare. And don't forget the weekly doses now on Apple Podcasts and Spotify, so be sure to subscribe. There's a ton of new healthcare related legislation and regulations coming out of Washington DC right now. And one of the most important pieces of legislation was signed into law last December. The No Surprises Act was passed by Congress to protect consumers from surprise medical bills, those medical bills that come unexpectedly and often with high price tags. Additionally, the No Surprises Act also bans balance billing for some out of network care. So all this is good news for consumers. But heading into 2022, it means hospitals and insurers are determining how to implement the requirements of the No Surprises Act . They finally got some guidance from the federal government, which released its interim final rule on the act in late December. So what's at stake with the No Surprises Act , and how the new rules affect patients, hospitals and insurers? Here to discuss the legislation or Lisa McDonnel of UnitedHealthcare and Michael Wentzien of Naviguard. Lisa is Senior Vice President National Accounts. And Michael is CEO of Naviguard, Lisa McDonald and Michael Wentzien, welcome to the podcast.
Lisa McDonnel01:32
Thanks for having us.
Michael Wentzien 01:33
Thanks, Eric. Glad to be here.
Ira Apfel01:36
So let's start with the basics. What is a surprise bill? And why have they garnered so much attention in recent years? I'll throw the one over to you, Michael.
Michael Wentzien 01:44
Great, thanks, Ira. surprise bills, a medical bill for emergency service or a medical service that was unknowingly outside of your insurance network. And balance bills have garnered attention because on average, nearly one out of five emergency room visits across the US result in at least one surprise bill. And these bills can really add financial stress when patients are trying to recover. When you think about this, more than 40% of people who receive a surprise bill report a cost of over $500. And it's estimated that over 45% of Americans worry that major health care event will bankrupt them. So this is definitely an industry issue.
Ira Apfel02:26
And what requirements are included in the No Surprises Act ? And also how big a deal is the No Surprises Act on the healthcare landscape? Lisa?
Lisa McDonnel02:35
Well, it's a pretty big deal. And it definitely impacts plan sponsors, who are ultimately accountable for compliance. It really starts with the Consolidated Appropriations Act. And in addition, there's the No Surprises Act and the transparency and coverage rules that are in totality, I have laid out a number of requirements that plan sponsors need to and payers, insurance companies need to comply with the complexity and the cost associated are fairly significant. We know that because of the business that we're in, and the data and information and systems that we have, that our plan sponsors really need us to help them comply. What the No Surprises Act does, is it really bans balance billing for an out of network service. In the following categories, emergency services, air ambulance services, and services provided at an in-network facility by an out of network or otherwise, you'll hear referred to ancillary provider. An example of this last category is an anesthesiologist if you go in for a procedure at an in-network facility, but an anesthesiologist who's out of network and supplying that, that Anastasia, you could be stuck with a bill. And the No Surprises Act is really stepping in to protect members. The law requires for the services that the member cost share would be comparable to what they would pay had they received those services from an in-network provider. But the law really only protects the consumer, it is not playing placing any kind of cap or dictating the reimbursement for the provider and therefore the provider can still come after the plan for more reimbursement. So it does outline some processes by which the provider needs to adhere in order to seek additional reimbursement. But it does not limit what the provider can ultimately try to go after with the plan sponsor.
Ira Apfel04:55
So it sounds like consumers are I'm not gonna say off the hook but it kind of moves The issue away from them is that correct?
Lisa McDonnel05:02
It is correct. In fact, the initial amount that will be calculated for the consumer out of pocket portion is dictated by the law, we will follow that for our customers. And we will apply that amount. It's known as the qualifying payment about or qp. A, once that amount is calculated, and the member is charged their portion, they will never see or should never see any additional bill for those services, it that that amount is kept, the provider cannot seek additional reimbursement per the law from the from the consumer. So they are protected, which really kind of brings now into question, what should the reimbursement be for the services between the plan and the provider?
Ira Apfel05:56
Michael, I'm curious just to make sure that people get a good idea of this, when is the No Surprises Act take effect. Let's start right there.
Michael Wentzien 06:08
This law takes effect for plan effective dates on or after January 1 of 2022.
Ira Apfel06:16
And we sort of spoke about a little bit about the impact on patients booklet in your perspective, from your experience. What do you think? The no surprises that will mean for patients? And what where does the no surprise that not protect patients to questions? There for you
Michael Wentzien 06:34
those are great questions. And police did a great job outlining the law and many of the details and there are many details in the NSA and it greatly improves the impacts on consumers that they've increasingly encountered over the years. So what that means for patients is for services that fall into those categories that are protected, providers will not be able to bill you for a month higher than what your cost share would have been had you seen in a network provider. And you're also protected from surprise billing. If you would need an air ambulance. Again, you'll only be responsible to pay for in a similar service. This is important to note that the NSA does not protect patients from balance billing for ground ambulance. So there are some nuances in there. And to put a finer point on that I'd like to kind of highlight where the NSA does not protect patients. In general, if a patient chooses to receive care out of network, which we all do, sometimes those surprises will not apply. So if you have to see a doctor or specialist who is not a network, you'll have to use your out of network ushering which can be much higher than your network cost sharing and you may face of balance bill.
Ira Apfel07:43
Right, and I was just going to bed that, of course begs the question why do you? Why would you need an out of network program with a no surprises that then?
Michael Wentzien 07:52
Good question. You might say, hey, everything's covered, we're good. But there are a lot of out of network charges that are not covered and patients will continue to seek out of network care. And since the NSA does not cover all of these situations, plan sponsors still need a comprehensive other number of program like Naviguard to address the no choice situations like ground ambulance, for example, and choice situations where you may choose to go to your own orthopedic surgeon etc.
Ira Apfel08:20
Okay, so let's move on. Talk a little bit more about the impact on employers. How are employers Lisa expected to navigate the new regulations?
Lisa McDonnel08:31
Well, I'm not sure that, that the regulators, when they crafted the law weren't necessarily thinking about how employers themselves would comply. I think they envisioned that their carriers or administrators would really help them comply, which of course, we do help our, our clients comply with many laws today, that affect their business on the benefit side. And we have every intention of helping them comply with these rather complex laws. But some of the things that they would have to comply with, if they were trying to do it on themselves is figuring out how they would administer the different components of the IDR or independent dispute resolution process from the 30 day fee negotiation window to ultimately preparing briefing documents for an arbitrator, should the provider decide they want to go to arbitration, they also would need to understand any kind of plan restrictions, as well as some of the other requirements of the various laws. I mean, everything from ID cards, directories. All of those areas are impacted by this legislation. It's fairly broad reaching the work necessary is going to be really challenging for a plan sponsor and employer to do on their own. They would need a lot of data and information to really even defend the application of a go out rate and what is reasonable to reimburse for a service that might be done an air ambulance service, for example, or, or an emergency room treatments that is provided to really be able to win an arbitration, the parties are going to have to be informed by data, and have legal teams to prepare the information that would really convince an arbitrator to side with the plan and ultimately, win that arbitration.
Ira Apfel10:45
So arbitration is obviously a big, big issue here a big sticking point, Lisa. So how will arbitration be handled and who's going to do the arbitrator?
Lisa McDonnel10:54
Yep, full for our clients, we intend to do that and handle that on our client's behalf. So the after you apply the plan applies a go out rate, which you need to determine, to really position the plan best to either resolve the claim dispute with the provider, without going to arbitration, or ultimately to be successful in winning that arbitration. So there's a lot that goes in to just determining what that initial go out rate is. But beyond that, United will also support through our out of network partners like nab a guard, the 30-day required negotiation period. And that is a key period, within which we hope we are able to reach agreement with the provider on a settlement amount. Of course, we're targeting and hoping that that amount that we ultimately agree to with the provider is somewhere in the ballpark of par median, because we think now that you're taking the member out of the middle of these bills, that there is the opportunity to really rationalize what is paid for the services, and to really draw upon what is typically paid for these services on an in network basis as at least the basis for what you would price that claim at and where you would try to defend that amount. So that will be handled by NASA guard for those customers that have the NAB record program. And then, you know, they are going to really utilize that deep industry knowledge that that historic information about where providers have agreed to accept reimbursement for these services. And they do just a phenomenal job of negotiating and resolving a large number of those claim disputes today. And that is why they are best positioned to do that going forward. We've helped in the nav ecard program, a number of clients resolve issues and I'm going to have Michael kind of provide a bit more information on that.
Ira Apfel 13:12
So that leads me to the next question, Michael, which is how does nav a guard or company like Naviguard helping the situation
Michael Wentzien 13:20
as Lisa pointed out, Naviguard will help support the negotiation process, which is key to try to find that agreed upon rate so we can avoid arbitration with those our network providers for NSA cover claims rare ambulance etc. We also continue to support non-NSA covered claims grounding led through situations where members choose to seek behavioral health care from an out of network provider or others. For example, we've assembled a great team here at Naviguard. And our deep industry knowledge means we understand the ins and outs of this new legislation for the point of view of the patient's employers, providers and insurers is there's many different areas of focus here that we need to be thinking through.
Ira Apfel14:02
So is this the end of the story? Are we going to have to revisit the No Surprises Act and surprise billing down the road?
Michael Wentzien 14:09
Right now it's unclear how providers will react to the new law, the NSA changes out of network billing favorably for patients, and it does not eliminate it completely, as we've talked about it and shift some more burden on a plan sponsors. Just as never guard is ready to support the current surprise billing environment for our customers this year. We're prepared to fully support all the requirements beginning on January 1 22. We've been adjusting our offerings to support our employers with the new burdens they're going to face. Everyone should appreciate the value of a great partner to address NSA in the evolving of the network plan landscape here and we look forward to partnering with UHC and our customers to provide a distinguishing focus service here. One thing I'd like to point out though, is that the as Lisa talked about at the beginning, the NSA is only part of this significant piece of legislation called the Consolidated Appropriations Act. And UHC is partnered with Naviguard to address the NSA pieces. And I think we should share some of the broader efforts that UHG's undertaking to address all of the new regulations. It is it is highly complex to support our customers. And I think we should share that with the folks here.
Ira Apfel15:21
Surely, so go for it.
Lisa McDonnel15:23
I'd be happy to Thanks, Michael. So some of the areas that the consolidated Appropriation Act include are some requirements that have to do with ID cards. Our plan is as of January one to have our online digital cards comply with those requirements. And then the next time that eight and employer requires ID cards be printed, the ID cards will physical ID cards will be updated to meet these requirements as well. provider directories, there is a lot of requirements in this area. One of the components of the CA requires insurers and health plans to have processes in place to verify provider geographic information, constantly, it is every 90 days, providers validating that information. And really, the intent here is to make sure that member responses are accurate, that they have accurate, updated current information available to them and that there are processes in place to hold them harmless. There are additional items like One example is the preservice EOB requirement that ended up getting delayed from its original effective date in early 2022. That is a requirement that we do see coming likely in 2023. And so there will be more rules, more items going into effect.
Ira Apfel17:00
That's Lisa McDonnel of UnitedHealthcare and Michael Wentzien of Naviguard talking about the No Surprises Act . Thanks so much for listening to the podcast. Be sure to subscribe on Apple podcasts or Spotify and have a great rest of your week.