To put patients first, put an end to surprise coverage

Research paints a consistent picture: consumers ultimately judge healthcare quality based on their personal experience.

While the heart of this experience is their interaction with a physician or clinician, it does not end there. Too often, it ends with an unpleasant letter telling them what their health insurance does not cover.

Some call this surprise billing. I call it surprise coverage, leaving patients uncertain about what they owe versus what the insurance company is going to pay. Due to the proliferation of high deductible health plans (HDHPs), narrow networks and care denials - patients are often surprised by their bills whether they visit an in-network or out-of-network provider.

As the nation's largest physician staffing firm with 25,000 physicians and clinicians who staff hospital emergency medicine, radiology, anesthesiology and neonatology departments, Envision Healthcare dislikes this dysfunctional system as much the confused patients do. Although the vast majority of our physician services, delivered at over 1,800 clinical departments in 45 states, are covered by insurance network contracts, we have taken fire for sending patients out-of-network bills.

To be clear, Envision’s business model is delivering quality, patient-centered care – not surprise bills. That is why we launched our Patients First Initiative to work with hospitals, health systems, insurance companies, legislators and advocacy groups to drive change and resolve challenges with coverage and billing.

It’s important to differentiate among the sources of surprise coverage.

Narrow networks. Insurance companies are increasingly restricting which providers and healthcare facilities are in-network. As more physicians are excluded, the possibility of patients receiving care, and higher bills, from out-of-network physicians increases.

High deductible health plans. HDHPs are becoming increasingly prevalent because they reduce upfront premiums in return for much higher out-of-pocket and deductible responsibilities. According to the Centers for Disease Control and Prevention, about 43 percent of Americans with private health insurance enrolled in HDHPs within the first six months of 2017 compared to 26 percent in 2011.

Denial of care. A more recent trend is insurance companies denying emergency coverage altogether. Even when both the hospital and physician have in-network status, they may deny claims after the fact because they determine the patient’s condition did not qualify for emergency care. Consequently, patients are burdened with the entire bill. This practice violates the prudent layperson standard, which calls for insurers to pay for emergency care based on a patient’s symptoms, not the final diagnosis. Like it or not, in the U.S. healthcare system, emergency departments serve as an important safety net for patients. While there is consensus that not everyone who seeks emergency treatment needs it, it is important to remember that doctors have a duty to treat patients in the emergency setting regardless of payment arrangements. This is a matter of both federal law and professional responsibility. Moreover, fear of denial can deter patients who are experiencing life-threatening injuries from seeking appropriate medical treatment.

It doesn’t have to be this way.

There are opportunities to standardize billing practices, improve contracts between insurance companies and physicians and, most importantly, protect patients from unexpected gaps in care coverage.

Envision is leading by example. In February 2017, Envision announced plans to move most of our out-of-network physician services billings to in-network status over an 18 to 24-month period. Back then approximately $1 billion, or 12% of our $8 billion annual revenue was from privately insured out-of-network sources.

In 2017, Envision moved $500 million of that revenue to in-network status. So far in 2018, an additional $100 million of previously out-of-network revenue has already been converted to in-network status.
Further, Envision Healthcare is on-track to shift more than 70% of the previously $1 billion out-of-network to in-network revenue. By end of 2018, less than 5% of Envision’s overall revenue will be out-of-network.

We also support state and federal legislative efforts to end surprise gaps in coverage, improve healthcare transparency and create a fair reimbursement strategy for physicians, hospitals and insurance companies.

Some of the efforts we support include:

• Protecting patients from balance billing from out-of-network physicians at in-network facilities
• Establishing stronger network adequacy standards that hold insurance companies responsible for providing the appropriate access to in-network care and certain medical services
• Creating an independent dispute resolution process through which patients can request an independent review of their bills
• Establishing a uniform method to determine usual, customary and reasonable (UCR) payments and enact a UCR rate that is in the 80th percentile as defined by a fair, accurate and independent charge database.

Payors, regulators and providers must work collaboratively to achieve these solutions. Everyone wins when we put patients first.

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