New proposal would make insurers gatekeepers for medical billing
The policy proposal prescribes shifting the billing and collections effort from individual providers to insurers, thus creating a centralized billing process.
A newly published policy proposal imagines a United States health care system where insurers, not individual providers, take over the responsibility of collections and billing.
Among other benefits, the authors tout their proposal as an answer to “surprise billing” — the problem of out-of-network billing that has vexed consumers, employers and legislators.
Authors John Sackett, COO of Adventist HealthCare, and health care consultant Allen Dobson call their plan the consumer protection realignment, or CPR. The policy proposal prescribes shifting the billing and collections effort from individual providers to insurers, thus creating a centralized billing process. The proposal, the authors say, would address several flaws in the health care industry such as stingy cost-sharing, provider administrative fees and the high cost of care.
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“We propose a realignment of the billing and collection of deductibles, coinsurance, and copayments from health care providers to health insurance plans,” the authors wrote.
Shifting these duties to insurers, the authors say, will increase the risk that insurers will take on debt. This new risk would incentivize health plans to reverse the trend of increasing out-of-pocket costs for patients, as insurers look to avoid incurring debt from consumers who cannot pay their medical bills. Additionally, insurers would be in a better position to negotiate reduced health care rates.
The providers would see savings from the elimination of the risk from uncompensated care costs, as well as the substantial administrative fees incurred from collections, follow-ups and consumer assistance, the authors say. According to a 2018 study, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure.
Consumers would see lower costs of care and a streamlined, user friendly process. The authors offer up a scenario where a shoulder surgery patient receives several bills from different providers — the anesthesiologist, surgeon, internist and hospital — including a surprise bill if even one of the providers is out-of-network. Under the CPR, which forbids almost all instances of provider billing, patients would receive one bill payable to the health plan. Another provision of the policy would require that patients sign a waiver and be handed out-of-pocket costs estimates if a provider is out-of-network.
“Given that the out-of-network provider is now in dialogue with the plan,” the authors wrote, “a collateral benefit of CPR is that the provider would eventually consider joining an insurance network, fully protecting their income and their patients from surprise billing costs.”
In another boon to consumers, the plan requires that the savings generated for providers be used to negotiate reduced payments and savings for plans.
The authors note that these changes must be enacted legislatively. They add that more research is needed in order to most effectively implement the policy, including realistic estimates of provider savings and quantitative analyses on rate cuts for services.
“We expect and welcome public debate by stakeholder groups on the operational feasibility and legislative and regulatory possibilities of CPR,” the authors wrote. “Given the status quo of our health care system; such debate is overdue.”
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