Specifically, Section 802 of the Sanders bill would cripple the health care system and reduce or eliminate access to care for patients and communities. That would save hundreds of billions of dollars in funding for hospital care, while generating windfall profits for commercial health insurers.
The AHA strongly opposes policies that reduce hospital reimbursement by eliminating “facilities fees,” the direct and indirect costs of keeping hospitals serving patients and meeting community needs. ing. They fund 24/7 standby capacity with a high degree of urgency, provided only by hospitals and with no payers to cover all costs. The AHA is also deeply concerned about clauses that dictate reimbursement rates between payers and hospitals and require hospitals to be responsible for insurance company claims.
Abolishing facility usage fees
Section 802 requires hospitals to provide medical plans and support for many services provided in off-campus HOPD and on-campus HOPD, including assessment and management, telemedicine, and certain “low-complexity services.” It is prohibited to charge the issuer a facility usage fee.
We urge Congress to reject any legislative proposal that would result in unprecedented cuts to hospitals and healthcare systems and significantly jeopardize patients’ access to essential care.
- Current payment policies take into account the fact that HOPD and other outpatient care settings are fundamentally different from other care settings. Hospital facilities are more expensive because they treat patients with more serious chronic conditions than those treated in clinics and ambulatory surgery centers. It also disproportionately cares for the uninsured and individuals enrolled in Medicaid programs, and the financial losses associated with caring for these patients must be met through other sources of income.
- The cost of care provided by hospitals and health systems also takes into account the unique benefits that hospitals and health systems provide to communities that are not provided by other care facilities. This includes investments in maintaining standby capacity for natural and man-made disasters, public health emergencies, and unforeseen traumatic events; includes investments made to provide 24/7 emergency care to
Rate setting
Section 802 also restricts providers from “charging more than the Qualified Payment Amount (QPA)” for goods and services provided in an office environment. This pricing approach reflects an attempt to statutoryly set payment rates during negotiations over the Surprise Medical Claims Bill and, in fact, is part of the statute codified as part of the Surprise Prohibition Act. I am referencing.
We urge Congress to reject this legislative proposal and any other proposals that would allow the government to determine payment rates between two private entities.
- Setting a statutory rate, without assurance that health insurance will pass these savings on to consumers through lower premiums, would result in significant economic gains for the insurance industry.
- Using QPA results in artificially low reimbursement.
- Such rates do not capture the many factors health plans and providers consider during negotiations, such as business, quantity, quality, health plan history with respect to pre-approvals, payment delays or denials. The administrative burden imposed by a particular plan.
- Health care facilities with higher cost structures, including those providing tertiary and quaternary care such as trauma and burn care, require more expensive equipment and specialized staff. This also includes smaller hospitals where the workload is low and therefore the overhead cannot be spread across many services.
- Adoption of QPA-set rates is likely to undermine the hospital’s ability to provide ambulatory services in the area, and it is unlikely that other providers will be able to meet those needs.
- Since QPA is known only to health insurance plans, it is operationally impossible for hospitals to charge more than QPA.
- The QPA was designed to calculate a patient’s share of the cost of a particular out-of-network service and as a basis for consideration by arbitrators of provider payments during the independent dispute resolution process. The QPA shall not be deemed appropriate or final. Provider payout rate.
- Requiring hospitals to charge no more than a QPA would make the calculation difficult, as there could be dozens, if not hundreds, of different QPAs for the same service, depending on payer and type of medical plan. This significantly increases operating costs.
single invoice
The provisions of section 802 refer to a prohibition on health care providers from “sending separate bills from health care providers and facilities to the patient’s or group’s health care plan or health insurance issuer for specified goods or services.” doing.
The AHA believes that the proposal would make hospitals responsible for sending a single bill for services provided to patients, and perhaps in turn, insurance companies that would compensate the various providers involved in the patient’s care. I am against it because it suggests that I will be held responsible.
- Physicians who provide services at on-campus or off-campus HOPD facilities may not be hospital employees, and hospitals may be responsible for making medical insurance claims on behalf of independent practitioners.
- This approach places a greater administrative burden on the hospital, as the facility must negotiate directly with the practitioners to determine their payment.
- Hospitals will assume the role of traditional insurance companies in negotiating contracts, as well as bearing the financial risks of both themselves and their physicians.
- This approach would add significant administrative costs to the healthcare system, as hospitals would have to replicate systems and data sources currently managed by insurance companies.
A separate identification number is required for off-campus outpatients
Finally, Section 802 would require each off-campus HOPD to claim using a separate, unique health identifier, and that these HOPD not submit claims to physician bills using the new unique identifier. You are prohibited from submitting claims or billing patients for goods or services for as long as possible. Type (HIPAA X12 837P or CMS 1500).
The AHA opposes the provision because hospitals are already transparent about where care is provided on their bills. Hospitals and other health care providers bill according to federal regulations and can bill all payers (Medicare, Medicaid, private payers) with a code that indicates where the service is provided. We sought. This provision will also create a significant administrative burden for health care providers and health care in general. That would require a complete overhaul of current billing practices and systems, placing a heavy burden not only on providers, but also on payers and third-party vendors.
