Health Law Talk Presented by Chehardy Sherman Williams
+ Full Transcript
Rory Bellina (00:15):
Hello everyone, and welcome to Health Law Talk, presented by Chehardy Sherman Williams. Before we get started, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, and YouTube – links in the description below. We hope you enjoy this episode. Good morning everybody, and welcome to this week’s episode of Health Law Talk presented by Chehardy Sherman Williams. I’m Rory, and I’m here with Conrad Meyer. And today’s topic is Balance Billing. Conrad, you excited to talk about balance billing?
Conrad Meyer (00:50):
You? You know, it’s, it’s, it’s probably the least like from a consumer standpoint, the, like, the least fun thing to discuss, even from a provider standpoint, it’s, it’s not dry, it’s just, it’s, it’s like, it’s like one of those little, I guess things you don’t, you won’t be able pull back the covers and you’re like, Oh, I have to look at that. Correct.
Rory Bellina (01:08):
Right. And like you said, everyone from providers to consumers, we’ve all been to the doctor or been to the emergency room, or, you know, had a child or a specs, a child. We’ve all gotten, we’ve probably all gotten a surprise bill or attempted to balance build. So we’ve all been there no matter what side you’re
Conrad Meyer (01:24):
On. It is the worst feeling in the world when you do that. And at least the thing is, is that we understand what that is. Like, in other words, like, okay, I can’t wait to get the four bills I’m gonna get now because I went to the facility at a hospital somewhere. But, you know, a lot of people don’t know, even though what that is, they don’t know, understand what a balance bill is, and, and, and they don’t even understand how the process works if you go to a facility. So I thought we would start maybe discussing how that works and, and how the process works.
Rory Bellina (01:51):
I think, I think that’s a great intro to this episode. And I think we should start with kind of giving an example. The emergency room example is a good one because unfortunately we’ve probably all been through that talking about when you go to a facility, what happens, We’re gonna get into what balance billing is, some changes in Louisiana and some impossible changes that are gonna go forth nationwide and
Conrad Meyer (02:11):
The federal level. Right?
Rory Bellina (02:12):
So Conrad, you walk into the emergency room mm-hmm. , or you have to call an ambulance and get to discuss that as well. But you walk into the emergency room, you think you broke your leg. So what possibly happens?
Conrad Meyer (02:25):
Okay, so I, well, do I walk in the emergency room or do I call 9 1 1 and have the ambulance come and pick me
Rory Bellina (02:31):
Up? Let’s, let’s do a full example. You, you, you call 9 1 1. Okay. Your foot is so bad. It’s your right foot. You can’t drive yourself to the hospital.
Conrad Meyer (02:39):
I can’t drive myself.
Rory Bellina (02:40):
Conrad Meyer (02:41):
Am I at home or am I on vacation?
Rory Bellina (02:45):
Let’s, let’s go with the at
Conrad Meyer (02:46):
Home one. Okay, let’s, good, we’ll
Rory Bellina (02:48):
Go with the in. We
Conrad Meyer (02:48):
Won’t all these No, look, all these things matter because it does, we’re talking about in-network and outta network facilities. So let’s just, Okay, so I’m at home, I break my, my foot, my ankle, correct. And I call 9 1 1. Okay? So ambulance comes, picks me up, right, Right, right. I go to the er and let’s just say I go to a, a, a facility that is not, or you know, in network mm-hmm. with my insurance mm-hmm. . Okay. So, so,
Rory Bellina (03:11):
Or soon that they are, We can do both examples.
Conrad Meyer (03:12):
We can do both examples we’ll do in-network and outta network. So you wanna do in network first?
Rory Bellina (03:16):
Let’s do in network. We’ll
Conrad Meyer (03:17):
Do network in easy one first. Okay. So in network, my hospital,
Rory Bellina (03:20):
Can you tell your ambulance driver bring me to this hospital? I know for
Conrad Meyer (03:24):
Sure it’s in network. It’s in network. Okay. So how I go to the hospital through the ambulance, I’m arriving at the er, I’m checked out by the er and usually they’re can take some x-rays right of my foot. Right. Which you need to be, you know, evaluated by an ER physician. Mm-hmm. . Okay. So ambulance driver takes me evaluated by ER physician X-rays taken by a radiology tech, which need to be read by a radiologist. Mm-hmm. , right? Mm-hmm. . Okay.
Rory Bellina (03:44):
Here. Now another fact, your broken ankle is so bad that you’re gonna need surgery.
Conrad Meyer (03:50):
Oh wow. Okay. So, okay, so I have an immediate surgery. So let’s just say now I’m going to the surgical suite. So I’m gonna have an orthopedic surgeon, most likely from from a group, let’s just say a group, not a hospital employee. and an anesthesiologist who’s gonna have to put me under
Rory Bellina (04:06):
Likely some blood work
Conrad Meyer (04:07):
Before blood work. So that’s gonna involve lab, right? Right. And then also probably a, you know if let’s just say it’s a bone fragment, right? Right. We might have to have pathology confirmed that’s a bone fragment. So, so let’s just look at all the providers that just went through that process, right?
Rory Bellina (04:22):
Surgery grows, goes great, you get discharged, you go home, your ankle’s perfect, a month goes by.
Conrad Meyer (04:28):
What’s the, Okay, so let me guess. I, I feel like there’s some sort of a question coming in. How many bills am I gonna get? That’s
Rory Bellina (04:33):
The question. That’s the question. Oh, wow. You went, you told your ambulance driver. Bring me to X hospital. I know it’s in network, so Right. A month goes by, you’re walking around on your newly healed ankle with plates in it and screws in it. Oh boy. Everything’s great. You go to your, you walk out to your mailbox with your new ankle and
Conrad Meyer (04:50):
I felt miserable with a new ankle.
Rory Bellina (04:51):
What do you get in your mailbox?
Conrad Meyer (04:53):
Oh, I, I would think so let’s walk through the process. I’m probably gonna get a bill from the ambulance company right from the running. Okay. The ED group who is not unemployed by the hospital, cuz they’re gonna bill me separate. Correct. then I’m gonna get a bill from the radiologist group who is not a part of the hospital. That’ll be a third bill. Correct. Then I would get a bill from possibly the lab company as a separate entity. So depending if it’s with in-house outhouse. Right? Right. then I’m gonna get a bill from the pathology group that will review the bone fragment to make sure that it is actual bone for my ankle. Right. Right. Cause they’re not part of that. That’s the RAPS physicians. So then I’m gonna get a bill from the ortho who was not employed from his group. Yep. And then I’m finally gonna get a bill from the hospital
Rory Bellina (05:35):
And anesthesia and, and all
Conrad Meyer (05:36):
Forgot Yes. Anesthesia. Yes. Yes. Very good. So,
Rory Bellina (05:39):
And your hospital facility bill, how
Conrad Meyer (05:41):
Many bills was
Rory Bellina (05:41):
That correct? It was like six. I lost count, like
Conrad Meyer (05:43):
Six or seven. I lost count. You
Rory Bellina (05:44):
Know what you told the ambulance company bring you to this hospital. You think in your mind I pay my insurance premiums, my employer pays some or, or however it may be. I pay, I’m covered. I’m covered. This is covered. I’m going they told me this hospital is covered. I did everything right.
Conrad Meyer (06:01):
But what if, what if Right. The ortho was not in my network. Right.
Rory Bellina (06:09):
How would you know though?
Conrad Meyer (06:10):
I would have no idea.
Rory Bellina (06:10):
Exactly. And that’s the part that I think we need to discuss with our listeners or explain to them. You thought that your hospital that you chose was in network and you did that. Correct? Right. That’s right. You know, beforehand, I can go to these hospitals, they’re in network, but let’s explain to our listeners the difference between a hospital being in network and then all of those services you just had not being in network or not being participating providers. So what do we commonly see? I know you and I both see this and, and it’s a, it turns into a numbers game, but what do you commonly see with these hospital structures in our emergency room example?
Conrad Meyer (06:49):
Well, I think, well, well I think if the facility’s in network, right? I know that my facility payment will be covered by my insurance company. So I’m happy with that, right? Correct. So whatever deductible I need to pay mm-hmm. , I know that it was covered comma, but right now I’m having have six other bills to deal with from those other providers who maybe in or were not in network, outta network. Right. So you know, if suddenly I’m, I’m, I’m confused, I’m like totally confused. I’m trying to figure out, wait a minute, why am I getting six bills for one service?
Rory Bellina (07:21):
Because they were all in the hospital. When you arrived wearing scrubs providing services, you thought they were under the hospital umbrella?
Conrad Meyer (07:29):
I did. And, and not only that though, it’s an emergent care for me. Correct. It’s not elective. I didn’t say, well, hey, today I’m gonna take a trip to the hospital, let
Rory Bellina (07:37):
Me pick Dr. Rory to Right. To read this lab or to put me under or whatever may be they just showed up and, and I’m
Conrad Meyer (07:43):
An emergency, I’m an, I just broke my ankle or whatever I did. Right. And so now I feel like I had to go get taken care of and so suddenly I feel like I just had a gotcha moment. Correct. You follow me.
Rory Bellina (07:54):
A lot of people feel that way. They feel that
Conrad Meyer (07:56):
They got me.
Rory Bellina (07:57):
No one told me that the, the orthopedic surgeon was out of network. No one told me that the anesthesiologist wasn’t part of my plan. No one told me that the lab was out of network.
Conrad Meyer (08:07):
And this happens every day.
Rory Bellina (08:08):
Every day. So numerous people and, and I think it’s important to discuss the, the reasoning why it happens. So under the typical hospital system, you have employed physicians, you have independent contractor, provi or I’ll say providers. So you have employed providers, you have some that are independent contract, and then you have some that are
Conrad Meyer (08:27):
Just have privileges
Rory Bellina (08:28):
Correct. That just have privileges that are, that have relationships with the hospital, but they’re not under that hospital umbrella per se. And they might not take insurance. So they might be considered an out of network provider, but you have no way of knowing that as the consumer because you went to the hospital and they were there.
Conrad Meyer (08:45):
No, I have zero way of knowing that. And now suddenly instead of one payment, I thought that was gonna be made, I have to make six more or whatever, 5, 6, 7 more Correct. To cover all these physicians that maybe were in, or providers that were either in net outta network. Now, if they were in network and they submitted a bill and I submitted it to my insurance company, they should be paid. Correct. And I wouldn’t have to worry about it. But again, I I, I can’t sit there and say, Hey, before you take me under the knife, doctor, can you tell me if you’re with Blue Cross or can you tell me with Humana or Aetna or Kaiser? Right. Can you tell me that? So
Rory Bellina (09:18):
You get, you get a bill and let’s say it’s from the surgeon and it says that they provided X, Y, Z CP to CCPT codes. And for this,
Conrad Meyer (09:26):
Well, they might not know what a CPT code is.
Rory Bellina (09:29):
Okay. They provided these services Services, right. These services, and here is our rate. And then next to that little box, it’s gonna say insurance paid zero. So what likely happened is that your surgeon submitted the bill or had your insurance from the hospital submitted the bill to your insurance. And let’s use the Blue Cross example. Blue Cross said, Oh, hold on, surgeon, you’re not in network with us, we’re not paying you anything. So you need to go collect
Conrad Meyer (09:58):
Depending on the plan, right? Correct. Depending on an individual’s plan. That’s correct. In this case, we’re saying that they didn’t pay
Rory Bellina (10:02):
Under our example, you would need to go collect from the patient. And that’s unfortunately what happens. So I think that’s the, that’s a exam, a real life example of what happens. And the the reasoning is because you have a lot of these providers that are in hospital systems that are just have privileges there or they’re, but they’re not actually in network with your insurance. Right. And, and it’s really hard for the consumer to understand that, but it happens every day. So there are some protections in place and there are some things that have been changing or evolving to protect the consumer. So let’s jump into balance billing now. Okay.
Conrad Meyer (10:41):
So, so now that we’ve defined it, we define that now a provider in this particular case, several providers right. Who are not in network or suddenly coming after me for my broken ankle because my insurance didn’t pay them anything. Correct?
Rory Bellina (10:53):
Correct. So I’m gonna change the facts now. You now go to the same hospital. Okay? Same exact situation. You have an employed physician that’s in network with your insurance mm-hmm. . Okay? The, that employed physician performs a surgery, right? Submits the bill, your insurance pays a, let’s say your, let’s say the bill’s a $4,000 surgery bill and the insurance pays him $1,000. What is that surgeon gonna do with that difference?
Conrad Meyer (11:27):
Well, I think that’s different now because, because of the employed status and if the hospital’s a network, then he would also be considered a network then they can’t balance bill me, they have to accept the $1,000 payment. Correct? It’s, and the other part of the bill has to be written off. That’s part of that in-network contract,
Rory Bellina (11:46):
Correct? Correct. So let’s talk about balance billing and kind of how it’s structured now, how it protects people and what it’s, what its intents are to protect against.
Conrad Meyer (11:58):
Well, I think, I think l for example, Louisiana has its own state regulations that protect and, and, and, and basically give the, the lay of the land on what, what providers can do, right? And can do with respect to balance billing. So for example, in network providers cannot balance bill a patient because they’re in network, they’re part of a contract, right? So that, so they’re by, by not only by state law, but also by the contract itself. Most all of the pro insurance contract payer contracts provide, you cannot balance bill our members if you’re in network, Right? So that’s a good thing. But then, you know, there’s some nuances in Louisiana law. So for example, if, if, if the insurance payer right in network doesn’t pay the full amount under the fee schedule, right? So, you know, so they short, they slow pay. Oh, not slow pay, short pay or Right. Then that doctor can balance bill only up to what he was contractually owed under that agreement. But how’s the patient supposed to know that
Rory Bellina (12:56):
They’re not, they’re
Conrad Meyer (12:57):
Not gonna, And you, and, and do you think the ballas bill’s gonna say, Well, hey, patient x John Doe. Right? You know, con Red Meyer, right? Hey, you, you, I had Blue Cross was supposed to pay me a thousand dollars. They only pay me 800, you owe me $200.
Rory Bellina (13:09):
Right? They’re not, And what
Conrad Meyer (13:11):
Do you think a patient’s gonna do? They’re gonna call Blue Cross and say, Hey wait a minute, I just got this. What are you talking about? Right? This is an in-network doctor, very confusing. Very, very confusing.
Rory Bellina (13:21):
Do we want to change the example that we gave and say that now you, your broken ankle was the result of an injury, a car
Conrad Meyer (13:28):
Accident. Oh boy. Now we’re really throwing a curve
Rory Bellina (13:30):
Ball. So you’re in a car accident and someone else was at fault.
Conrad Meyer (13:34):
Rory Bellina (13:35):
You go to the hospital. Same example.
Conrad Meyer (13:38):
Rory Bellina (13:39):
Conrad Meyer (13:41):
Well, I think now, now that it’s a PI case that’s different. So now the facility provider or what have you, we’ll go after the tort visa. Correct. So, so instead of just going after the insurance company, they’ll say, Okay, you know what, whoever caused the accident that we’re gonna go after, you we’re gonna go file a lien against you for causing the injuries that we had to care for and now we want to get paid.
Rory Bellina (14:05):
Right? And it adds, it adds a totally different concept. Now what happens if the person that provides you those services is in network and you’re still in that accident and you have insurance?
Conrad Meyer (14:16):
Well, I think that’s, that’s a different, that’s another scenario. So I think we’re going into a collateral source rule mm-hmm. on a, on a PI case. And that’s now changed Correct. In Louisiana. So you would have to show that the care provided was directly related to the injury sustained and that you needed to be made whole, but then still the provider could forgo the insurance payment Right. In lieu of collecting the bill charges for the PI case. Right?
Rory Bellina (14:48):
Conrad Meyer (14:51):
That, I mean, do you see that that’s, that’s three different really good examples, but totally different scenarios. Right? Right. you know, and most people I don’t know would see a, a PI case, but I think people would definitely see in network provider versus outta network provider. Right. And we don’t just have the, the basis for this just people understand the basis for not balance billing on in-network providers was because Louisiana itself has a, a prompt pay law
Rory Bellina (15:20):
Conrad Meyer (15:21):
For in-network contracted providers that, that I insurers must pay them timely or face consequences. So for, you know, all these special things for end network providers, the, the, the state says, Well hey, if you’re in network, we’re giving you all these little special things for prompt pay and, and, and, and even recourse on recoupment issues, which we’re not gonna get into today. Right. But for that you can’t balance bill patients. Right. And I know the, the payer contracts themselves also have provisions to say if you’re in network, you can’t balance bill patients. But here’s the, here’s the problem. So here’s the unique problem here. So to your example, let’s say I’m going outta town or someone comes to New Orleans and they have an emergent condition and they go to the hospital, same situation, they can get six, seven bills
Rory Bellina (16:07):
Because their insurance is likely for out of state and
Conrad Meyer (16:09):
Out of state. And the problem is though you’re in an emergent situation, you can’t control that. You’ve gotta go to the hospital. Correct. And you have to have emergency services. So a while ago, Louisiana tried to pass a bill that basically was a way to, to stop that gotcha moment. Right? Right. And it was a, I call the RAPS bill, radiology, anesthesia, pathology, emergency services. And basically they were saying if you have to go to a non-network facility that you have to receive emergency services that you will not be able to balance bill a patient mm-hmm. for those services, it didn’t pass.
Rory Bellina (16:47):
Right. And why do we think it didn’t pass? I think this is a great segue into let’s switch to the provider or the hospital side. Yes. If you’re a group, if you’re a an ER group, you know, you share er privileges with a group or like our ortho or anesthesia example, why do we want to be able to balance bill or why are we against all these changes to prevent these, these differential billings?
Conrad Meyer (17:12):
Well, I think from a provider standpoint, so I’m switching hats now. Sure. providers, I feel like they’re already out of network. They’re having to they’re not gonna get reimbursed anyway or the, the, the reimbursement’s so low, Right. Because normally what, what, what what payers would say in this situation is, well, if you’re outta network, we’re gonna reimburse you only what we would have paid an in-network physician to do the same procedure.
Rory Bellina (17:45):
So they’re essentially forcing you to to be to network without a contract contract.
Conrad Meyer (17:49):
That’s correct. But here’s the problem. You don’t know what that in-network physician would’ve been paid cuz you’re not in network. Correct. And all in-network physicians aren’t paid the same. Right.
Rory Bellina (18:01):
Every provider agreement’s different,
Conrad Meyer (18:02):
Every fee schedule’s different. So, so who, who’s to say that that payer is saying, Okay, we’re gonna pick the lowest guy right? Or the lowest girl, we’re gonna pay him that fee. So they getting paid in a very, very low amount mm-hmm.
Rory Bellina (18:15):
And, and they didn’t agree to it. They did not, they did not sign a provider agreement with the insurance to take that rate. So they feel that they a fee schedule, right. They think their services are worth x X and they’re being told no, they’re worth X minus 80%.
Conrad Meyer (18:29):
There’s no priv a contract. Correct. So there’s nothing there. So Yeah.
Rory Bellina (18:34):
So but what do they do then?
Conrad Meyer (18:36):
Well, the only option they have is to go after the patient. Right. And when the patient, you know, is gonna, you know, cry foul and get upset about that, which I mean, I mean obviously they will Correct. You know, you just have to say, well call your, call your insurance company patient X and, and complain to ’em that I’m not in network. Now there’s a whole bunch of other games we haven’t talked about mm-hmm. , we haven’t talked about payers manipulation of the network. Right? Right. Because if you think about it, for example, you know the largest here in Louisiana’s Blue Cross, Right? Over 70%. So if you’re a provider and you want to get into Blue Cross Network, they could just say, Okay, provider, you, we have so many orthos mm-hmm. , we have so many dur you know, GI guys Right? You have so many of those. So we’re only gonna pay you x percent plus Medicare. Mm-hmm. take take it or leave
Rory Bellina (19:29):
It. Take it or leave it. Exactly.
Conrad Meyer (19:30):
And if you don’t take it, I mean, there’s no negotiation. Yeah. If you don’t take it, Okay, fine. You’re not network.
Rory Bellina (19:35):
Right. And you miss out on this huge population pool.
Conrad Meyer (19:38):
70%. Yeah. I mean it’s kind of like, hey, if you don’t, I mean, I gotta take it. I have no choice. Right. I’ve got no choice. So,
Rory Bellina (19:44):
Or if you don’t take it and stay out of network, what administrative hurdles are you gonna face trying
Conrad Meyer (19:49):
To Oh, the balance bill patients. I mean, you’re gonna be, your back office is gonna drive you nuts. Yeah. Right? And then you, and then you’re, you know, you’re going to a collections nightmare. Because if you think about it, when they are out of network, the payers, now this is from the provider’s standpoint, right? Do not send the checks to the, to the providers, they to the patients.
Rory Bellina (20:08):
Correct. So now you’re calling the patient who’s already mad that they’ve got a huge bill from you and you’re trying to collect more money from them
Conrad Meyer (20:16):
And, and who’s to say that the patient hasn’t taken that check and saying, Hoo, I’m gonna go to another vacation and spent that money.
Rory Bellina (20:22):
Exactly. And then you have, and then the provider who’s out of network has to hire a collection company who’s gonna charge 30% it to
Conrad Meyer (20:29):
Go, Oh, it’s, it’s, it’s a terrible situation.
Rory Bellina (20:31):
It really is. You’re really, it it’s really, I I see in, in, I think it depends on the practice area, but you see more and more people going in network to avoid these administrative
Conrad Meyer (20:42):
Issues. Well then, then here’s another thing. Let me throw this at you because I don’t think we’ve talked about this and it’s this. Okay. what if you’re not playing by the quality assurance rules or the performance improvement rules of the payer, which they can set
Rory Bellina (21:00):
At arbitrarily. Right? And you have
Conrad Meyer (21:02):
To agree to at only spend this much time with patients. We only want you to see this. We’re seeing you spending way too much time here, or you’re spending too much on, on therapeutics here. If you don’t play ball well, we’re gonna kick you outta the network.
Rory Bellina (21:15):
Or if you don’t refer your labs to an WE network
Conrad Meyer (21:18):
Provider Oh, to to to Quest or you’re Lab Corps. Right. You don’t get to refer ’em to this. You must refer ‘EM request. Mm-hmm. , if you don’t do that, you’re out.
Rory Bellina (21:24):
Yep. Or, or we’re gonna cut your rates.
Conrad Meyer (21:27):
Right. We’re gonna cut.
Rory Bellina (21:29):
They have the ultimate authority. The payers ultimately have the ultimate authority
Conrad Meyer (21:33):
In this. So what, what what seems to be the common theme here.
Rory Bellina (21:36):
The payers are in control. The
Conrad Meyer (21:37):
Payers in control. That’s right. And, and nobody wants to hear that, you know, mean if you’re a payer attorney, all we’re not in control. We all, we do everything. You know, it’s, it’s everybody else but us. Mm-hmm. , the funny thing is, is a long time ago I I mean I was doing a lot of this work, you know, maybe 10 years ago mm-hmm. with the providers who were outta network. And I remember going up to the insurance commissioner and talking to them about why is it that the law says that insurance checks for outta network providers must go to the patients. Right. Why can’t we say that payers must pay the providers? And you know how hard that was to discuss? Nobody wanted to hear it. Yeah. Nobody wanted to hear it.
Rory Bellina (22:15):
Yeah. Because they, they, I think the concept behind that is that it’s, it’s out of network so that that money goes to the patient and it’s at the patient’s discretion to pay which patient’s not going to want to pay. Oh,
Conrad Meyer (22:26):
Rory Bellina (22:27):
So the, the question that I get a lot from new, from new, and then from, I think as providers go later down, their, their career path is most new providers coming out of, you know, residency, fellowships starting their practice, they’re gonna wanna be in network. Do you agree with that? Absolutely. And because you get that 70%, because if you’re starting a new practice, let’s say you’re starting a, you know,
Conrad Meyer (22:51):
Why would you not want 70% of the population at least a working population, Right?
Rory Bellina (22:54):
Correct. Because you’re gonna get a phone call or you’re gonna, you’re gonna get on your intake packet. We only accept these insurances or we accept no insurance. You’re cutting out a huge portion. Now, I know you’ve had some recent experience with this. You’re getting phone calls from providers saying, I don’t want to be in network anymore. Yes. And what are the reasons why you’re hearing that?
Conrad Meyer (23:16):
I think the reason that, that, that I’m hearing it is, is simply because they’re tired of the fee schedules. Yep. That’s the first thing that
Rory Bellina (23:24):
Are always going down.
Conrad Meyer (23:24):
Always, always. You know, you get a, you get,
Rory Bellina (23:27):
I’ve never seen a fee schedule go up.
Conrad Meyer (23:29):
No. But premiums go up. Correct.
Rory Bellina (23:32):
So where’s Right? The question is, where’s the money going? Premiums are going up,
Conrad Meyer (23:36):
But, you know, in Obamacare, they’re supposed to spend, and we, I mean, I know we’re getting beyond this topic here, that’s okay. But the medical loss ratio, so there was a mandate on under Obamacare, aca Right, Right. For medical loss ratio. And, and so that was the amount of money that a premium was supposed to be spent on actual care versus administrative, administrative duties. So you know, and, and I could see that. I think, I think what people wanna see and, and even providers is pay, pay a fair fee schedule. Right. Be transparent. and people wanna say, Well, if I wanna go to the hospital, then I, I, I don’t want to have six bills come to me. Now, here’s an interesting thing. So I know we’re gonna talk about the federal legislation in just a moment jump. And one thing that, that we haven’t, and I want to quickly just quickly mention this, is this value based reimbursement, Okay?
That is, they have pilot pro projects. Now it’s, it’s, it’s here in a set in essence where there’s a pay per episode of care. Now we haven’t, we’re not gonna, this is beyond this, this, this, this podcast. That’s okay. But, you know, normally when we’re doing fee for service, you know, there’s a different model. People say fee for service encourages over utilization. Now we’re going through this value based reimbursement, Right? which is just paying for an episode of care. So for example, using my broken ankle example that is, is a specific CCPT code. Correct. ICD nine, ICD 10 code, actually. And based on that code, the insurance, if they would’ve modeled, the government would pay one check mm-hmm. . And that one check would supposed to come with the facility, the ER doc, the ambulance run, the er, the radiologist, the pathologist, the or everything for that one episode of care. What’s the problem with that?
Rory Bellina (25:25):
? All of those providers are gonna be fighting for their cut of
Conrad Meyer (25:27):
That. Well, true. Right? But who’s gonna get the payment? Number one, is it gonna be, if it’s a facility, but since now the OR doc, the, the ortho doc was never had a, was not employed. He doesn’t have a contract with that facility.
Rory Bellina (25:41):
Right. So what’s to say at the hospital doesn’t give a, a fair share to those
Conrad Meyer (25:46):
Disagrees to, to him or to the pathologist, or to the re how do you, how do you divvy up that pot?
Rory Bellina (25:51):
Conrad Meyer (25:51):
And and do you think the government’s telling you how to do it?
Rory Bellina (25:54):
Conrad Meyer (25:54):
Absolutely not. Right. And, and if, if the government doesn’t tell you how to do it, do you think the insurance company’s gonna say, Well, here, here’s how you divide ’em up.
Rory Bellina (26:00):
No. And so it’s gonna be a less to the hospital and they’re gonna do what’s we,
Conrad Meyer (26:03):
We’re gonna tackle that in another episode. So let’s, let’s, let’s move it now. So talk about the new federal legislation that’s been coming out.
Rory Bellina (26:09):
Yeah. So, and, and kind of the name for it is No Surprises Act. this, this re was enacted under the Consolidated Appropriations Act earlier this year. And this is not going to effect until January 1st, 2022. So
Conrad Meyer (26:23):
We, so I know you’ve read up on this, So, so, so tell us what is the no, no surprise act
Rory Bellina (26:29):
Mean? Yes. So the big one, the big one in here that I’d like to talk about is if you have a non-emergent service and you go to a in-network facility, right? So your ankle, your ankle example, it’s hurt, but you’re gonna schedule that surgery. So
Conrad Meyer (26:47):
It’s, it’s elective.
Rory Bellina (26:47):
It’s elective. So you choose an elective procedure, right? You go to the hospital that the same hospital, not example that’s in network, but the, the surgeon that you pick is out of network. So the new rules are going into effect next year. Or that that doctor has to provide you written notice. They have to obtain consent, explain to them that they’re not participating or that they’re not in network, and they have to give a copy of that consent to you. Now, the big thing about this is that the provider has to give you a air quotes, good faith estimate of charges within three days of scheduling the service. And they have to do a, an advanced e o B. So let’s go back to putting on your provider hat. What is that gonna do for the provider and their back office and trying to estimate what a good faith estimate of that charge is gonna be. And are they gonna want to do that? Because now you might go shop around,
Conrad Meyer (27:45):
It’s gonna drive them crazy, is what it’s gonna do. But, but from a provider pat, right? I mean, the variables in that is so broad,
Rory Bellina (27:54):
Right? What if you get in there and it’s much more than
Conrad Meyer (27:58):
A three hour surgery. You thought a two hour, a one hour surgery, you thought now you’re having a six hour surgery and you gave the patient, you know, here’s my good faith estimate. Right. You know, but there’s outliers.
Rory Bellina (28:09):
Absolutely. Absolutely. And you’re, and, and are you gonna get into a battle where, well, the doctor told Conrad that it was only going to be $1,000
Conrad Meyer (28:17):
To absolutely gonna get into a battle,
Rory Bellina (28:19):
But they get in there and the surgery goes long. And so now the surgeon is having to pay anesthesia is having to all these different things that are going into that quote, per se, of the thousand dollars.
Conrad Meyer (28:29):
Well, wait a minute. Why does the surgeon have to do that? Doesn’t an anesthesia now have to give their own good faith estimate of the anesthesia?
Rory Bellina (28:34):
That’s a good
Conrad Meyer (28:35):
Question. Or does the pathologist have to give the good faith estimate of his review? Of the pathology?
Rory Bellina (28:38):
And, and I’m gonna put on the patient’s hat now. So I’m a, I’m a patient and I’m scheduling my elective surgery. I’m gonna have to get a quote per se from my surgeon, from the hospital for what? They’re, well not, not the hospital from anesthesia. How am I going to know that, that sounds about right. That sounds like a good quote for an ankle surgery. How do I know as a patient what, what these services are
Conrad Meyer (29:04):
Worth? But that’s the point. I mean, there’s no national database for a patient Right. For the patient. Correct. To look up and say, hey. Correct. Well, well technically you can look up CPT codes from Medicare, but I mean, Right. When you go back and you could say, first off, if you even understood what that was, right? If you knew the CCPT codes for that procedure and then you’re gonna go back to a doctor and say, Well, I went to this website on CMS and they told me for this ankle that you’re gonna do for me on this C P T, it’s only gonna cost you two or $300. So that sounds like a good deal to me. And they’re like, Well, wait a minute. That’s Medicare. We don’t, you don’t, you’re comparing apples to oranges.
Rory Bellina (29:41):
And now are you, as the patient, are you gonna be faced with having to negotiate a price for a surgery,
Conrad Meyer (29:46):
For an elective surgery for
Rory Bellina (29:47):
An elective surgery with a doctor? Or are you going to call around different doctors and say, Hey doc, what do you charge for a two hour ankle surgery? I’m comparing you with another doctor. It, it,
Conrad Meyer (29:57):
So wait, so let me, let me stop you right there. Cuz I think we had a good point, right? Putting my provider hat back on. Okay. Imagine having to do all of that for an elective surgery, plus all of the documentation you have to do to file claims, all the documentation, deal claims to get paid, right? It’s, I think it was, it’s good intentions, right?
Rory Bellina (30:18):
Conrad Meyer (30:19):
Nightmare. Yes, I think so. I mean, exactly on both sides. I think it, I think, I think on the consumer side, it it, it’s a nightmare because you don’t have a database Correct. Where you can compare. And, and then again, and then of course, you know, if I’m a doctor and I say, Well, you know what, I don’t care what that thing says. Right?
Rory Bellina (30:34):
Conrad Meyer (30:35):
If you want me to do it, it’s gonna cost you X.
Rory Bellina (30:37):
And I could be wrong, but me personally as a, I’ll put on my patient hat mm-hmm. , I choose my providers based on their reputation. So if they say it’s gonna cost X amount, I’m probably just gonna stop there and say, Okay, yeah, I’ll, I’ll go with it. I don’t, I don’t know if that’s good or not, but I want you, So are we gonna get into the issue where patients are, are shopping around looking for the lowest price and then we’re gonna have providers having to say, Oh, well Dr. Conrad down the street’s charging $200 less for this surgery. So
Conrad Meyer (31:05):
Go see Dr. Conrad.
Rory Bellina (31:06):
Yeah. Or do I need to adjust? Do I need to constantly adjust
Conrad Meyer (31:10):
My Well that, but then you know what though, Rory, I can see this happening. Like, it’s gonna open up Pandora’s box. It’s, and suddenly it’s gonna be like, Well wait a minute, you know, it’s not fair. Right. You can hear that coming. You can, you know, Absolutely. Let’s not, that’s not fair that this doctor’s charging more. So we’re not equal. It’s not fair. I mean, cuz you know, you’re doing a lot, you’re seeing a lot of that right now in every day. But I, I think it’s got, you know, what’s, what’s that quote? All, all good intentions or what, you know, pain. Yeah,
Rory Bellina (31:37):
I know what you’re saying.
Conrad Meyer (31:38):
Anyway. I think it’s got good intentions, but I think, you know,
Rory Bellina (31:44):
I know’s a
Conrad Meyer (31:45):
Tough one. Tough,
Rory Bellina (31:45):
Tough. It’s gonna be a tough one. And to see how this shakes out, I think we’re gonna see a lot of providers that, you know, they’re gonna try to comply with it. But I think that it, like you said, administratively, it’s gonna be a nightmare. Good intentions, good concept.
Conrad Meyer (32:01):
Butt, Don’t me wrong. Let me say this. I mean, I think, I think patients want transparency. Correct. I mean, would you, would it be nice if you went to an office, and I’ve seen this in
Rory Bellina (32:10):
Practices, and we have an episode planned on this, on hospital pricing and transparency
Conrad Meyer (32:13):
Rules. Yes. Yes, we do. And and I think that’s gonna come up and I think it’s a good topic because I have seen some concierge practices, for example, that you walk in Yep. On their website. Here’s, here are the costs. Right? No, no hidden agendas. No nothing. If you want this, this, Now, amazingly, it’s a lot lower than their bill charges, but, but that’s
Rory Bellina (32:34):
The cost. That’s the cost, Correct. And it’s very cut and dry. Yep,
Conrad Meyer (32:37):
Yep, yep. So, I mean, I think, think, I think, you know,
Rory Bellina (32:39):
It’s gonna be evolving. I think this is, I think balance billing is gonna continue to evolve. It seems like here in Louisiana every year there’s a house bill or a Senate bill, something that’s coming out trying to, to tweak this. I think it, it’s getting close, but you’ve got a lot of dueling agendas or dueling, you know, issues involved. You’ve got hospitals that that’s, you know, some hospitals want this. You’ve got big provider groups that don’t want this. You’ve got patient advocacy advocacy groups that do want this. So it really depends on, on who,
Conrad Meyer (33:09):
You know, what hat and, and who, who you have, who’s
Rory Bellina (33:12):
Pushing that agenda, that rep, that senator to introduce it. So that’s true. It, it, it’s, it’s, it’s an evolving issue. The goal, I think the, the one takeaway that we could both agree on is that balance billing, the goal is to protect the patients from getting these surprise bills. And I think that’s a good goal. But I think that there’s so many layers behind that and so many moving parts and parties that it’s hard to just accomplish that. It, it’s really hard to accomplish that and to outline rules to do that, to think of every scenario, because there’s so many scenarios with this. I think I, that’s what the, the legislators is constantly struggling with and constantly trying to tweak.
Conrad Meyer (33:53):
Oh, I mean, I guess we’re gonna have to see, you know, Yep. What happens next. And, and of course if we, if we do get some legislative proposals here in Louisiana, I’m sure we’ll bring it to everyone’s attention on a good podcast. So Yes, I agree. I agree. Thank you very much, Rory. I appreciate that. I think those are final thoughts for the fi for the balanced billing. Hopefully, hopefully neither one you and I, you know, get, get another balanced bill. Right.
Rory Bellina (34:17):
Hopefully we’re done with those. I know. No
Conrad Meyer (34:19):
More, No more. No more surprises. No more surprises.
Rory Bellina (34:22):
Alrighty. Thank you for listening to Health Law Talk presented by Chehardy Sherman Williams. For more information or to contact us, please visit our website linked in the description below. Also, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, and YouTube – links in the description below. Thank you for listening.
Have you ever been to a hospital that you thought was “in-network”, only to receive a bill sometime later from an “out of network” provider? In this week’s episode of Health Law Talk, Conrad Meyer and Rory Bellina discuss “balance billing,” including what it is, how it works (and doesn’t work!), and changes coming on the state and federal level!
Health Law Talk, presented by Chehardy Sherman Williams, one of the largest full service law firms in the Greater New Orleans area, is a regular podcast focusing on the expansive area of healthcare law. Attorneys Rory Bellina, Conrad Meyer and George Mueller will address various legal issues and current events surrounding healthcare topics. The attorneys are here to answer your legal questions, create a discussion on various healthcare topics, as well as bring in subject matter experts and guests to join the conversation.