Surprise Billing in Your Practice

Physician's Practice®: Today we are presenting our conversation with Steve Avery, president and chief client officer at Abeo—a company specializing in revenue cycle management—where we discuss the practice of 'surprise' or 'balance billing' and how practices can navigate this increasingly complex landscape.

Our conversation specifically addressed anesthesiology practices; however, the general takeaways should also be applicable to primary care solo and small group practices.

We began by discussing whether or not there are ways for practices to know ahead of time if a patient coming to their office is covered under a partnering insurance plan.

Steve Avery: Well, I guess the first thing is, I want to add a little perspective around that question. Just in the country, there are thousands of health insurance plans. And not every health insurance plan has prominence in every community. So, the average anesthesiology group working at community hospital may have about 30 to 40 health insurance plan-specific contracts. So, it's not out of the question that a patient could come to the hospital with an insurance policy, that's not one of the 30 to 40 plans that are under contract with the anesthesiology group.

For the providers that we work with, they're all very diligently working to have contracts in place with the insurance companies that are likely to have patients in the area. The answer to the question is that anesthesiologists may not always know if a patient is coming to the hospital that has an insurance policy that's under their contract. The situation can be further complicated by an unfortunate occurrence where the patient is coming to the emergency room to be treated and then straight to the operating room, very little may be known about the patient at that time, especially the type of health insurance that they may have; unfortunate, but it happens like that sometimes. So, you know, we don't always know ahead of time.

Physician's Practice®: If you are able to identify that a patient is not covered under a partnering insurance plan, you may be able to communicate this coverage discrepancy prior to performing services.

Steve Avery: Well, if you do know ahead of time, and there are certain times where we may get a tip off from the hospital, that patient's not covered under one of the insurance policies, the optimal situation is to reach out to the patient well ahead of the data surgery, and let them know that the provider doesn't have contract with their particular insurance company.

This gives the patient the opportunity to work with their surgeon to select another facility where the anesthesiologist does have a contract with their specific health insurance plan. So where you know ahead of time you can make, you could make alterations or change the location of the surgery just to make sure that the patient has the best outcome possible.

Physician's Practice®: Avery did provide three things that practices can do to ensure that a patient is prepared to meet the cost of your services.

Steve Avery: Yeah, I think there are really three things that they can do.

Its first, you know, work with the patient. Second work with the insurance company. Third, involve the patient where necessary to work with their own health insurance company to resolve any situation.

The patient needs to know what to expect. And really, communication is very key. They need to know what happens after the surgery and what financial impact this may have on them as a result of the procedure. So, what you have to do is tell them that you're going to work with them, try to ease their anxiety about the unknown. And many times insurance companies will work with the anesthesiologist to negotiate a more favorable reimbursement rate, that will reduce the financial impact on the patient. In the case of an emergency where the patient could not select the hospital, much less the anesthesiologist, the insurance company may offer rates and terms for the for the provider that really kind of mirror the reimbursement that a provider would normally receive if they were under contract for that particular insurance company.

Physician's Practice®: Beyond discussing payments with patients, balance billing has been cited as a negotiating factor for practices.

Steve Avery: Balance billing legislation really does more to complicate things for the anesthesiologist than it really resolves. In many states where legislation is in place, the insurance company sometimes has a negotiation advantage over the anesthesiologist. If the anesthesiologist does not have a contract, they're reimbursed usually at a very low reimbursement rate typical for that particular geography or not typical with average reimbursement rates for that geography. And then to complicated things they can't build a patient for any unreimbursed portions procedure.

If they do have a contract, then you know, complications occur when they try to go back and renegotiate any terms or any increase in reimbursement. It becomes less than likely, since the alternative is to have is to not have a contract, and really become a financial disadvantage in the marketplace. So, the question should be does the legislation benefit the patient? Or the insurance company? Maybe both. In many cases, it does not benefit the physician, they're now at a disadvantage in those in certain circumstances.

Physician's Practice®: So surprise billing generally complicate aspects of the treatment process for both the patient and physician or practice. Should this then be something that practices are actively attempting to suppress, or will it remain something that just occurs at the end of the treatment cycle?

Steve Avery: You know, I think they should, and practices should work to have contracts in place with all the insurance companies that are under contract with the hospital; mirror what they do. And many times, for groups, this is a contractual requirement. In order for the anesthesiologist to have a contract provides services at the hospital, they have to agree to have contracts with all of the insurance companies that are contracted by the hospital. I think it's also a matter of ethics, meaning providers should want the patient to have a positive experience when they're being taken care of. In short, they should want to help the patient medically and financially by helping them to navigate through what could be a very difficult situation.

Physician's Practice®: This may all come down to a question of reasonable costs – how then should practices be determining this reasonable cost?

Steve Avery: Well, anesthesiologists or any other practice for that matter are financial entities, and they need to provide market wages for the doctors and the supporting personnel that work for the practice.

The market really determines the wages in the in the area. They also determine the reimbursement for that provider in that particular mark. So sometimes, you know, when there's a political solution that tries to solve a specific problem, the market sometimes gets removed from the equation, just like in the surprise billing legislation. In this case, the provider becomes the one to suffer financially. If you let the market work, the anesthesiologist and the insurance company will in large part reach an agreement on what is reasonable reimbursement for the services they provide.