So, my name is Richard Heller, I'm a pediatric radiologist here in Chicago. And I have the pleasure of opening the session. So this will be a session on the issue of so-called surprise medical billing. It's a session in three parts. I get to open this. I'll be talking about what is surprise medical billing or so-called surprise medical billing, why is it important? Then we'll hear about the federal legislation on the issue, and then we'll conclude by hearing about how this impacts our patients. So part one, surprise, new federal surprise medical billing legislation to take effect, what radiologists need to know. So I saw this on Twitter. Surprise billing is one of the most evil practices in American healthcare. That's a bold statement, by the way. But you know what? It's Twitter. People say bold things on Twitter. So let's start with this. What is surprise medical billing? Well, first, it's actually a misnomer. It's a much better term, surprise insurance gap, because that's what it is. It's a gap in people's health insurance. And here's how I explain it in a very brief three-act play using the language of my children, emojis. So this is Emmy the Emoji. Emmy has private health insurance. So when Emmy got hurt at home, she knew just what to do. Emmy went to the nearest in-network hospital. They took good care of Emmy. They made Emmy feel all better. But then a few weeks later, Emmy got a big bill in the mail. It turns out that one of the doctors at that in-network hospital that she went to wasn't in her health plans network. And because that doctor at the in-network hospital wasn't in her health plans network, she owed a lot more money out of pocket than she was expecting. That's the surprise insurance gap or surprise medical billing. Somebody who has private health insurance gets unexpected care from a provider not in their health plan. And because they're not in your health plan, you owe more money. You the patient owe more money than you were expecting. So let's take a step back and just talk about how medical practice and all this works. So medical practices, like radiology groups, contract with hospitals to provide radiology services in those hospitals. Now, those radiology practices also contract with insurance companies to get paid for providing care to those patients. Separately, the hospital will contract with the insurance company, too. And what happens is the contracts that the insurance company has with the hospital and the contracts they have with their medical practices don't always line up perfectly. There can be gaps. And those gaps, that's what patients can fall through. That's the surprise insurance gap. A patient goes to the hospital, which is in-network, but that health network plan doesn't also cover the doctors there. That's the surprise insurance gap or surprise medical billing. And there is widespread agreement this is a problem that needs to be solved. We need legislation to stop it. Now, it's interesting because everyone who thinks we need legislation to stop it believes that the reason for surprise medical billing legislation is one thing only, that it's only about one thing, protecting patients. And that's true. That's the most important part. The most important part of surprise medical billing legislation is protecting patients. Nobody questions that. It's patient-centric. It's the right thing to do. But what I want you to understand is that legislation to end surprise medical billing has two impacts. One of them is protecting patients. The other one is the ability to influence contract negotiations between insurance companies and those medical practices. Remember that slide I showed you that the medical practices have to contract with the insurance companies? Legislation on surprise medical billing has the ability to influence those negotiations. Don't take my word for it, by the way. This is the Congressional Budget Office, a nonpartisan organization. They said that policies to address surprise billing can have important consequences for the healthcare system because they affect negotiations between insurers and providers. That's what the debate around surprise medical billing has really been, this second impact, the influence on the negotiations. If you only take one thing home from my talk, I hope it's this. In many ways, surprise medical billing legislation is a Trojan horse being used by some to try to create legislation that will give insurance companies leverage in negotiations with medical practices. That they could get through legislation talking about ending surprise billing, talking about that first role of the law, protecting patients, but really caring about the second one, the influence it has on contract negotiations. Again, don't take my word for it. This is the nonpartisan Congressional Budget Office, again, more than 80% of the estimated budgetary effects of this proposal they were considering would arise from changes to in-network payment rates. And the bill would cause these in-network payment rates to drop by 15 to 20%. So let me be clear, what the CBO is saying is that laws, legislation to end surprise medical billing has the ability to reduce in-network rates. So you can imagine my frustration when I read this in the New England Journal of Medicine. Only certain specialties and investor-backed staffing firms that rely on out-of-network billing as a revenue strategy would see their profits fall. What's the narrative they're telling here? This is the greedy doctor narrative. What they're saying is, look, these doctors are intentionally going out of network to blindside patients. We're going to pass a law that stops them from doing that. And only groups that do that, they're going to be the only ones that are getting hurt. Only those out-of-network physicians are going to get hurt. What did the CBO just tell you? No, this is meant to impact the in-network physicians. So this narrative that you're being told, that's a false narrative. So let me put some things in perspective. How substantial an issue is this? So there's something called the Quality Payment Program that I think many of you have heard of. That's like MIPS. Remember MIPS, MACRA, all that stuff? Well, if you were to ignore it, be like, you know what, I just don't want to do that. It's a hassle. You can do that. But you're going to get a 9% reduction on your Medicare fee schedule payments if you do not participate. If you just totally ignore it, a 9% reduction on your Medicare position fee schedule payments. Recently there was a re-evaluation of these E&M codes, these Evaluation and Management Codes. That led to a 10% reduction in reimbursement for diagnostic radiology result. A 10% reduction in your Medicare payments. What about surprise medical billing? The CBO, as you just read, estimated a 15% to 20% reduction. And that's on your commercial rates. So it's nominally bigger, 15% to 20%. And it's on your commercial rates, which are often better than your Medicare payment rates. So how do we solve this? What are the principles that we need when thinking about ways to end surprise medical billing? Well, the first one, I think we all agree on. Take patients out of the middle. Hold them financially harmless. If you have private health insurance, if you did everything right and you got unexpected care from a doctor not in your health plan, it's not your fault, fine. You pay your normal in-network cost-sharing amount, whatever that is, you got to pay that. And then the insurance company will pay the rest. And also we should have some things in there to promote network adequacy. So insurance companies have to have an adequate degree of specialists in their network. And it should be transparent so people, beneficiaries, know who's in the network. As you can imagine, it was the second part that caused all the controversy. How much should insurance companies reimburse the providers for their services? Well, there were two approaches that were considered. The first one was a benchmark. Well, how do we value the service? Well, what are some benchmark numbers we can use? Medicare. Let's benchmark it off Medicare. Well, people quickly moved off using Medicare as a benchmark. Medicare was never intended to be a market-based rate, nor is it. So they moved off that. Then they had a second idea. Why don't we use the median of the in-network rates that the health plan already has? The 50th percentile. So here's how that story goes. Look, you're out of network. We're not going to give you the best rate we pay, but we're not going to give you the worst either. We're going to give you the median, the 50th percentile. This resonated. Like, when lawmakers heard this, when a lot of doctors heard this, it made sense. Here's the conversation that I had with a lot of practices around the country. You know, Rich, I know you really worked up about the surprise medical billing stuff, but I got to tell you, our practice, we're like 98% in-network. We've got great contracts. If I only get the median rate for 2% of my claims, I got to tell you, Rich, I'm not that worked up about it. I don't really care. What I had to tell those practices was, you're the ones they're targeting. You're the ones they're going after. Let me explain. So on the left, you'll see sort of the current situation, the existing system where we are right now. With 100th percentile and 50th percentile, let me put some numbers on this. Let's say the 100th percentile for some service is $100, and the median reimbursement for that service is $50. Now, you're in a good practice. You invest in QI. You do all the right stuff. You've got a $75. So your contract says you get $75 for that service. You're not the best, but you're above median because you've really put the work in. So when a law that benchmarks off the median in-network rate were to pass, you're going to get a letter or a phone call from the insurance company. And it's going to go something like this. So medical practice, you have two options, and we, the insurance company, we're cool with either one. You just tell me what you want to do. Option one, you can go out of network. Now, if you go out of network, you're not going to get $75. We're going to have to pay you $50. But it's not going to be fast. We want to hold on to that money and keep it invested as long as we can. But eventually, you're going to get your $50. You're going to have to file some paperwork and do out-of-network claims and jump through some hoops, but you'll get your money. Or you can stay in-network. We would love to have you in-network. If you stay in-network, you're going to get paid faster. You know what you're going to get paid. It's going to be cheaper for you. It's going to be easier. But you're not going to get $75. You might not even get $50. They might make it $45 because, look, there's a premium to be paid to being in-network, and they know that. Now, I made these numbers up, but the intuition is still there. If you pass a law benchmarking off the median in-network rate, what you have done is given the insurance companies the power to take the top 50th percentile, chop it off, and recalibrate everything. So the new 100th percentile, the top, becomes the previous 50th percentile. It's a very powerful way for insurance companies to ratchet down reimbursement. Now, the other approach is arbitration. The goal of arbitration is not to favor the insurance companies or the medical practices, but rather tell them, look, you all, you work it out between yourselves. You negotiate. And if you can't figure it out yourselves, you have to go to a neutral, non-conflicted, third-party arbiter, and they'll make a decision. But the idea is not to favor either side. So let's talk about New York, because they're kind of an interesting case study. So in New York, the way they used to do it historically was the out-of-network standard was something called usual and customary rate, UCR, usual and customary rate. And there was a database company which kept track of this UCR, this usual and customary rate. Now, the attorney general of New York got concerned, because that company that did database for the UCR numbers was actually owned by a big health insurance company. And so the attorney general was worried, because of that relationship, because they were owned by a big health insurance company, maybe there was a conflict of interest. So the attorney general did an investigation. And it turned out that there was no funny business, that everything was going appropriate. Of course, I'm lying to you. The attorney general's report found that the database intentionally skewed the usual and customary rates downward. Huge lawsuit, hundreds of millions of dollars, big lawsuit. But out of this lawsuit, out of all this, came the nation's first comprehensive surprise medical billing legislation. New York passed the first one, rooted in arbitration. And the New York report said that in less than four years, it had saved consumers hundreds of millions of dollars, had reduced out-of-network billing. And oh, by the way, radiology's role here, we were less than 1% of disputes. Texas also passed a law on surprise medical billing, based in arbitration. Interestingly, most of the cases there are said to be a teleconference before they ever get to arbitration. Their law has decreased consumer complaints 96%, and physician complaints 70%. But there's not consistency in the laws around the state. Some states have comprehensive laws, some have partial laws, some have no laws. There's no consistency. There's a lot of variability. So we needed a federal law. The other reason we need a federal law is because of ERISA plans. Now, I always mispronounce ERISA, but so I remember ERISA rhymes with Marissa, as in Tomei, the Academy Award winner. ERISA plans are these health plans that are self-funded. Like a big employer will have their own health plan that they self-fund. Those are called ERISA plans. And ERISA plans are actually under the jurisdiction of the federal government, not the state government. So when the states pass their laws, in general, the ERISA plans aren't part of that. And they're a large part of the private health insurance market. So if you want to end surprise medical billing, the surprise insurance gap, you've got to do with the ERISA plans. You've got to have federal legislation. So what did we see on Capitol Hill? We saw a variety of approaches. On the Senate side, to help health, education, labor, and pension, that committee wanted to go on a benchmark approach, or at least many of them did. They liked the idea of a benchmark, benchmarking off the median and network rate. The House Ways and Means Committee, they wanted to use an arbitration approach. And then sort of a hybrid model came out of House Energy and Commerce and also Education and Labor, also using more of a benchmark, but sort of trying to put those two together. So what happened? Well, in 2019, it looked like we were going to get a law. It's going to happen in 2019. We've actually figured it out. And what happened? The whole thing collapsed the last second. So on December 8th of last year, we were not surprised when it's going to happen, it's going to happen. And it collapsed again. It was deja vu all over again. If I'm being honest with you, the whole thing was very Ross and Rachel. Will they or won't they? I don't know. It collapsed again. But then on December 11th, it's back. It's going to, a deal was struck. We've heard this before. But it actually did stick. And on December 27th, the No Surprises Act was passed as part of a larger bill, the Consolidated Appropriations Act of 2021. So it was passed in December of 2020 and is due to start on January 1 of 2022. Now my colleague, Mr. Gaines, will be talking about this law, but I do want to make one point about it. Only the idea behind the law, the reason this was a struggle and all these compromises was because they wanted balance. You don't want to favor the insurance companies. You don't want to favor the providers. The whole idea of the No Surprises Act and the struggle was about preserving balance. Surprise billing is one of the most evil practices in American health care. I saw that on Twitter. Very true. But I think it's also one of the most misunderstood. Thank you very much. Thank you, Dr. Heller. Welcome everyone. It's an honor to be in front of you. I want to emphasize several of the points that Rich touched on with respect to the legislation. One of the reasons the NSA matters so much to us is it's the first time comprehensive legislation will address ERISA plans. ERISA plans are among your very best payers. Between 120 and 130 million people are employed in large employer plans by ERISA plans. So for example, in the state of Texas, which has a very comprehensive law, a very robust IDR process, approximately 20% of the plans in Texas are actually applicable to the Texas law. So this is the first time we've had broad protection for patients in ERISA plans. I think also it's important that the par-non-par discussion is different for you now than it was before because the patients are protected. As Dr. Sadiq is going to talk about, the patients are out of the middle of this, which is something that we have advocated for as a collective group of physicians and supporting organizations for many years. But the other theme that I think Rich hit very well is this has more to do with your in-network rates than it does really to do just with out-of-network in terms of his theme of this issue being misunderstood. All right. So the NSA was years in the making and in part what it attempted to do was identify states that had already addressed the surprise billing situation and deal with those. Now Dr. Heller went through several of the bills that were considered. Of those bills that were considered and pushed most strongly by the health plans were benchmarking bills. Again, trying to set the out-of-network rates at a median in-network amount. And that was rate setting to some in Congress and they said the federal government should not be involved in rate setting. If you look at this Commonwealth Fund site, which is pretty good, I don't agree with all of it, but it's a pretty good description of where the states are. You can see 17 states have no balanced billing restriction at all. I'm in North Carolina. The folks to the south in South Carolina have no restriction. North Carolina is listed as having a partial restriction, which is only specific to emergency medicine. And then 18 states, like Texas, have what's called a comprehensive protection. Now Dr. Heller already talked about this, so I won't go into this very point. But the fact of the matter is the benchmarking is what's focused on by the plans to drive those in-network rates to that lower point. Because the 50th percentile does then become the maximum. So if you're in-network, you're discounting off of that 50th percentile. And as he mentioned, the Congressional Budget Office scored those early bills in Energy and Commerce and the Pallone-Alexander Compromise. And they looked at those and they said that since most care is delivered inside of networks, that roughly 20 billion to 22 billion dollars of savings over 10 years was going to come from the declination of in-network rates. So this has always been, from the health plan's perspective, about reducing in-network rates. And I have to look no further than Blue Cross and Blue Shield in my own state, just a couple of weeks ago, sent, and they have publicly acknowledged this, 54 letters to groups of radiologists, anesthesiologists, and emergency medicine physicians demanding immediate, quote, interim reductions between 5 and 30 percent. The chair of the ACR this morning or last night took issue with that. They issued a public rebuke of what Blue Cross has done here, as have the anesthesiologists and the emergency physicians. And this is a plan in the state, ladies and gentlemen, that has 70 to 75 percent of the commercial market. So it is a very powerful health plan. Plus, for most hospital-based groups, you are required by your contract with the hospital to participate with plans like Blue Cross and Blue Shield. So you have a party here who is essentially demanding that you drop your in-network rates immediately or face termination of the contract, and you can't terminate them, because if you do, then you're in violation of your hospital contract. So it really creates a very, very difficult problem in terms of these issues. All right. So several critical takeaway messages that come out of this in the rulemaking, and one of which is the issues around the rulemaking as it related to the creation of a legal presumption where no one existed in the statute. As I mentioned, and as Dr. Heller was talking about, we resisted the benchmarking bills in Congress. Those were not passed. And what was passed in the No Surprises Act was a statute that required the consideration of a number of different factors that we'll talk about in a minute, but no factor predominated over any other factor. Unfortunately, in the rulemaking that was issued on September 30th, it made the median network rate really the predominant factor. There are also some requirements for physicians in terms of patient disclosure and good faith estimates, and we'll touch on those as well. All right, so at bottom, this law protects patients from out-of-network balance billing full stop if you're an emergency physician at an in- or out-of-network facility, if you're a radiologist at an in-network facility, or you're in an air ambulance situation. There are fines and penalties associated with noncompliance. Now, it does set up a process for independent dispute resolution, or IDR. One of the features of that is a mandatory 30-day negotiation period. That period does not begin automatically. You actually have to initiate that with a notice. You cannot jump the 30-day period. You can't cut it off at 20 days. You can settle with the plan, and if you settle with the plan, then you split the costs of the IDR at that point. Both sides, of course, are encouraged to reach those compromises. One of the things that the rule, as I mentioned, does is it sets the qualifying payment amount, which is defined as the median in-network rate as of January 31, 2019, adjusted for inflation. One of our radiology practice managers analyzed the inflation adjustment since that time, and he estimates that it's about 8.5% increase from the end of 2019. So in some people's view, the QPA could be actually a good deal, because many contracts don't actually have an inflation adjuster in them. So the QPA will become a factor in the IDR, and as we'll see, it is under the new rule the predominant factor. In fact, what they've said in the September rulemaking is that the QPA will be considered the presumptive final amount unless the physician presents credible evidence that materially demonstrates that the final payment amount should be different from the QPA. So instead of the statutory language, which says the IDR adjudicator shall consider all of the factors in IDR, what they've done in the regulations, they've created a legal presumption which did not exist in the statute. OK, so under the IDR process, after the negotiation period, each side has approximately 10 days to submit their information. This is baseball-style arbitration, so the adjudicator will pick one or the other offer, and the loser pays those costs associated with IDR, which for batched claims can reach about $670 after both sides pay $50 to go into the IDR process. Now, you can batch 30 days worth of claims, same or similar provider, same or similar geographic area, same tax ID. So you could put a number of CTs together. There's no financial limit. Some states have a limit or cap. There is no cap under the federal rule. But after that 30-day adjudication, you then have a 90-day waiting period where you have to wait before you can file a subsequent IDR. However, once that 90-day period expires, you can bring 90 days of claims into that next IDR. So there's a benefit there in terms of the batching aspect. All right, I mentioned the number of factors. Again, in the statute, the statute says the adjudicator shall consider the QPA, or the median allot amount. But they also shall consider the clinician's training or experience, the teaching status of the facility if it is a teaching hospital, quality and outcome measurements, acuity and complexity of care. And here's an important guardrail, prior contracted rates for the past four years. If I'm the adjudicator, that's a very compelling factor to me, is what were those prior contracting rates? Did that plan, like the Blue Cross example that we showed earlier, did that plan force me into a situation where I had to terminate? That's going to be a very important factor. Good faith or lack thereof of both parties. In the market share of the clinician or the health plan. Again, with the blues, market share will be a very, very important factor. State-specified laws. So the federal statute attempts to achieve federalism in a way that allows the state law, if it's applicable to both, has to be a three-part test. Is it applicable to the patient, the provider, and the plan? If it meets those three criteria, then the state law will control. However, as Dr. Heller mentioned, ERISA plans would not be subject to that unless they opted into the state. States like Georgia or Dr. Sadiqa's do have a voluntary opt-in process where ERISA plans can opt in. So ERISA plans could be subject to that. So as I mentioned, one of the things that we really objected to was the fact that the administration took a non-benchmarking statute and turned it into a presumptive benchmark. So what did we do? We filed a lawsuit about a month ago in Tyler, Texas. The Texas Medical Association and Dr. Adam Corley, who's an emergency physician in Tyler, Texas, claiming not that the patient protection provisions should be withdrawn or forestalled, only that the provisions that the administration said that the median and network rate or the QPA should be the predominant factor that those were objected to. So that lawsuit was filed. Now, there are a couple of mandatory disclosures that I will touch on very quickly. If you're in a hospital facility setting, you want to make sure if you're an independent group that your group is being covered by the hospital notice. There's a provision in the law that allows the hospital to do the notification for you. It's a disclosure about the NSA. And it's a one-page document, can be two-sided. It also has to refer to the state law requirements. So it's definitely something you want counsel to be looking at if you're an independent group to be sure that state laws are appropriately addressed as well. And there are links in the slide deck to the CMS notice. I would highly recommend you use the CMS notice as a way to achieve compliance. Finally, there is a provision in the law that allows an uninsured or a self-pay patient to receive an estimate in a non-emergency context for scheduled services to receive an estimate from radiologists, anesthesiologists, other specialists in the hospital. And in the case where you're a hospital-based radiologist, the statute considers you to be what's called a co-provider. And the hospital is the convening provider. So the hospital is the one who collects the estimates from the other specialties, puts them together for the patient, and presents those to the patient. Now, when I say self-pay, this would be a self-pay patient who might have insurance, but they don't want their insurance billed because they have a sensitive diagnosis, an STD, or some kind of HIV status, or other sensitive condition that they don't want billed. So as a result of that, then they would be entitled to receive the good faith estimate as well. And it has to be in good faith because there are certain rights that trigger for the patient if the final charges are actually more than $400 from the estimate. They have an entire process to go through dispute resolution. So that's another thing to be aware of and know that that will be a requirement for you if you're a hospital-based radiologist. Now, if you have your own imaging centers, then that makes your status as a convening provider. And then the obligation is on you to produce the good faith estimate to the patient. So those are very important. As I mentioned, there is a dispute process that's specific to patients who receive a final bill that's more than $400 from their estimate. And then they can go into their own unique dispute resolution process. And the key there is that you must not do anything that relates to collection activity around that account until the dispute process is over. So, I mean, we heard a lot about supervised medical billing and no surprise act so far. So my talk is going to focus on the patient implications of this legislation. So as we heard, the Department of Human and Health Services announced this rule to protect consumers from supervised medical billing. And this is one of the first series of regulations that is designed to protect patients from financial hardship that is coming from the supervised medical bill. Again, as we heard from the previous two speakers, the rule is supposed to restrict excessive out-of-pocket costs to consumers from supervised billing and balanced billing. So there are two things in terms of the supervised billing. One is, let's imagine a patient needs to go to an emergency department for an emergent issue. And obviously, the patient doesn't have time to look whether that emergency department is in-network for them or out-of-network for them. And in case that the department end up being out-of-network, they're going to receive a bill for an out-of-network, which is going to be a surprise bill. And then the second issue is that sometimes you have an elective procedure or elective admission. You have done your research. You have find any network provider. But in addition to that service that you're receiving, you're receiving some additional services such as radiology, pathology, anesthesiology. And those physicians are considered out-of-network for you. And you didn't know about that. And then you're going to get this surprise medical bill later. And then there is also an issue of balance billing, which is when a provider charges the patient the remainder of the price that the insurance didn't pay for the provider. And historically, patients who have Medicare or Medicaid insurance has been protected from balance billing. But the goal of this surprise medical billing and the legislation is coming is to protect patients supposedly with commercial insurance also from the issue of balance billing. So what is the scope of problem? So one in five inpatient emergency department cases has been shown to be led to surprise billing in 2014. And that percentage is around 14% for outpatient visits to the ED and 9% for elective inpatient admissions. And the highest rates of this surprise medical billing is in certain states. It's very variable across the country. But some states, such as New York, such as Texas, and Florida have highest rates of surprise medical billing. And the studies have shown that patients who receive surprise medical bill are going to end up paying at least 10 times more than the in-network services. So you can see that it's a huge financial burden on the patients. And on the other hand, there has been an increase in the rate of the surprise billing. Another study showed that between 2010 to 2016, the rate of surprise medical billing increased from around 39% to 42.8%. And it's not just the rate increasing, but the amount of dollar that the patients are getting billed is also increasing. This number increased from $220 in 2010 to $628. And that's a huge number if you think about the patient perspective. Actually, there was a recent study published in JACR. It was showing that for every $100 increase in out-of-pocket costs, patients are going to have less probability of getting their screening mammography. So now you think about a patient getting a bill around $600. It's a huge impact on the patient, on the family, and the patient needs to make sacrifices. From the radiology perspective, around 18% of radiology exams during an ED visit in an in-network hospital result in surprise billing. And the average amount of surprise medical bill for radiology services is around $115. And if you think about radiology exams that are happening during an inpatient hospitalization, again, in an in-network hospital, around 23% of them result in surprise medical billing. And the average bill is around $267. There's one other issue with these surprise medical bills. So they are not going to count toward the deductible. And out-of-network maximum of the patient. So imagine if you receive a surprise bill, and you have a chronic condition, you have a high deductible plan, you still need to pay your deductibles. You're still going to pay your out-of-network maximum. And the amount of money that you pay toward the surprise bill is not going to count towards that, which is, again, another issue from a patient perspective. So the underlying cause of surprise billing is these narrow networks that you see with certain insurance more. Like, you see this more often with marketplace insurance. I mean, obviously, a lot of these insurance that have lower premiums have created this model that they contract with only a few hospitals as an in-network to kind of shift the volume of their patients towards that hospital. And I mean, it's kind of like a benefit to both the insurance company and the provider. But from a patient perspective, it put patients at higher risk of receiving surprise bill. And studies, again, have shown that patients who have marketplace insurance are patients that usually receive more surprise medical bills just because, like, I mean, they have a narrower in-network. On the other hand, also patients who are at increased risk of severity and complexity of their treatment episodes are the patients that are receiving more surprise medical bills. Studies have shown that patients that going to have higher inpatient hospitalization and longer hospital stays, again, those are the patients that are going to receive more surprise bill. It makes sense because if you stay in a hospital for longer, the chances that you're going to receive services with some of those other providers that are not considered your in-network is going to be higher. But logically, it's not fair for the patient because patient is actually paying their insurance to have the insurance for the days of the need. And during the days of the need, I mean, that insurance is not covering everything and they're going to receive these high medical bills. There are certain consequences of surprise billing from a patient perspective. First of all, these out-of-network bills are burdensome for consumers. I mean, I'm sure many of you guys have experienced this, receiving a bill and then you think it's wrong. You think like it's more than what you expected. Now you need to get on the phone to talk to the provider billing office, to talk to the insurance. It's very frustrating for the patients, for the family. And it has actually been the number one complaint for the New York Department of Financial Services, and I assume it's the same for other states as well. The other problem with these surprise bill is it decreases the trust in the patient-physician relationship. Again, if you think about a patient that is going to a physician to receive the best high-quality care and they have this trust in their physician, they kind of expect their physician to know what they are ordering. Although, from a physician perspective, I mean, it's kind of like, I mean, difficult to expect them to know what type of services are being covered by the patients. But from a patient perspective, they have this trust in their physician. They're going to do whatever their physician order and now they receive the surprise medical bills. And then it exposes patients to financial hardship, which we're going to go over that. And also, it's going to raise the total cost of health care services. So on the issue of patient-physician relationship, we talked about, so patients want high-quality care at an affordable cost. We talked about the two episodes that we went over. Again, imagine a patient coming to the emergency department. They have abdominal pain. The ED physician orders CT scan to rule out appendicitis. Radiology is out of network for that physician. They receive a surprise bill. So now, if you think about the whole episode, the ordering of that imaging exam was totally appropriate. It was benefiting the patient. There was no harm involved. And the patient was also consenting to the process. They trusted in their physician and now they received a surprise bill. So this is one of those incidences that the surprise medical billing or the new legislation of the Surprise Act is supposedly to help the patients to avoid these sort of processes. Because in an emergency setting, it's kind of hard you expect that there is a discussion of the cost between the patient and provider. You just need to get the things done. I mean, there's no time to talk about cost or any sort of even shared decision-making in terms of the cost. But from an elective perspective, I mean, again, imagine a patient needs an elective abdominal surgery. So this patient, I mean, get their surgery. They need anesthesia. Anesthesia is out of network while the surgeon is in network. They, again, receive a surprise bill. Again, if you think about the whole episode, this was something that patient needed. It was appropriate. There was no harm involved. And the patient, again, trusted their physician. But here, there was some opportunity that was lost. The physician or the physician office or personnel had a chance to tell this patient that your service is not just surgery. You have this additional care, and your insurance is not covering these. And so this is one of those chances that are areas of missed opportunity that there is no discussion of the cost as part of that shared decision-making with the patient. And it's going to hurt that patient-provider trust. The other issue we talked about is financial hardship. I mean, it's a very hot topic in many areas. It's conditions that arise from high out-of-pocket medical expenses. One of them are surprise medical billing. And I mean, as we know, it causes medical debt. It can cause financial worry. Patients get anxiety because they can't afford it. And it has negative consequences on patients' care adherence. Patients are going to skip their visits. They skip their imaging. They skip their medication just because they can't afford it. And also, this financial hardship is a health equity issue, because everything comes in your socioeconomic context. Obviously, the patients that are of lower socioeconomic status cannot pay that surprise medical bill. Like, they are at more strain, and it's going to then affect their health outcomes in a much worse way. As far as the scope of financial hardship, one in 10 Americans reported financial hardship in 2015. 27% of adults would need to borrow or sell something to pay an unexpected bill of $400. So now, think about the $600 surprise medical bill and how it can impact the patient if a patient receives that bill. And two-thirds of all bankruptcies filed in the United States are tied to medical expenses. So what does this new Surprise Act does? We heard a lot about its impact on the providers, which is not fair. I absolutely agree. But from a patient perspective, it's kind of more of a double sword. And I'm going to go over that. One is, so, I mean, obviously, there's going to be no balance billing anymore. Patients only have to pay the cost-sharing amount that they would have paid if they were in-network. And this cost-sharing is going to count towards their in-network deductible and annual out-of-pocket maximum. So it seems like a very sweet deal. And also, with the good faith estimate that Gaines talked about earlier, so, I mean, you're expected to tell the patients beforehand for all aspects of that service that the patient is receiving what is going to be your estimate. And if patients end up receiving a bill that is more than $400 different than your estimate, then you guys need to go through sort of a dispute resolution process and talk about it. So again, thinking about this patient implication-wise, so, I mean, it seems like a very sweet deal. It provides patients with financial peace of mind while seeking emergency care. It safeguards them from unknowingly accepting the out-of-network care. And it's a good thing, but the problem is exactly what came out, like, and the discussion that, I mean, the previous speakers talked about today. I mean, with this new sort of, like, I mean, things that the insurers are doing, like the Blue Cross Blue Shield of North Carolina, I mean, is trying to terminate the providers that don't basically cut down their in-network rates. So what does that do to the patients? That's going to even narrow, more narrow their in-network access. And imagine if a patient already is, like, having established care with some provider. They have, like, a chronic disease or a complex disease, and now they need to change, like, their specialist. They need to change their care provider just because this new care provider is going to be considered out-of-network with them. So the whole thing is more of a, like, a double sword for the patients. While it's supposed to be very, very patient-sensory, but the way it's going to be handled, it can harm the patients in some aspects. And that was it to me. Thank you very much.

surprise medical billing

American healthcare

insurance gap

No Surprises Act

out-of-network care

independent dispute resolution

patient protection

healthcare legislation