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- CAP Urges House Committee to Provide Equitable System for Resolving Insurance Payment Disputes
On September 19, the House Ways and Means Committee held a Hearing on Reduced Care for Patients: Fallout From Flawed Implementation of Surprise Medical Billing Protections which shined a light on private insurers refusing to negotiate payment to physicians in good faith before arbitration, and not paying providers after there was a ruling in their favor. To put additional pressure on Congress to fix the failing IDR process, the CAP made recommendations to the committee and submitted a letter on September 29 that further detailed our advocacy on this issue on behalf of pathologists and patients. The recommendations are:
- Strengthen enforcement and addressing non-compliance issues
- Clarify consideration of IDR factors
- Ensure broader batching and appropriate fees
- Further formalize and/or centralize the open negotiations period
- Bring down the need for IDR disputes through appropriate reimbursement and network adequacy
It is vital that Congress ensure an even and fair playing field for all IDR parties, the CAP said. Additionally, network inadequacy is a growing problem that the CAP believes will only get worse, as “there will be even less incentive by health plans to offer physician practices a fair contract, or keep contracted physicians in their network, because their ability to underpay these physicians while out-of-network is now even easier.”
The CAP’s recommendations focused on minimizing insurer manipulation/underpayment and reducing utilization of the IDR process. To do this, Congress must impose strong financial penalties for those insurers that do not comply with the 30-day statutorily required timeframe post-payment determination. Congress must also ensure an accessible and transparent audit/complaint process and help guarantee a more equitable, accessible, and efficient system to fairly resolve payment disputes between providers and health plans.