Oct 25, 2019 - Health

New York's very expensive surprise medical billing solution

New York's surprise billing law — which providers hope will become the model for a national solution — has resulted in providers receiving some very high payments, according to a new analysis by the USC-Brookings Schaeffer Initiative for Health Policy.

Why it matters: Surprise medical bills impact two groups of people: The patients directly responsible for paying them, and the rest of us, who pay higher premiums as a result of their existence.

  • A solution resulting in higher provider reimbursements would still protect patients from enormous surprise bills, but it could raise health care costs and thus premiums.

Details: New York's law resolves payment disputes between insurers and providers — the heart of the surprise billing debate — by using an arbitration process.

  • State guidance says that arbiters should consider the 80th percentile of billed charges, or list prices. The problem is that these charges tend to be much higher than the negotiated rates that insurers pay for in-network care.
  • A New York Department of Financial Services report found that the average payment amount decided through arbitration is 8% higher than the 80th percentile of charges — a victory for providers.
  • This, in turn, is likely to raise physicians' leverage with insurers when negotiating payment rates.

Yes, but: The state's report says the law has saved consumers an estimated $400 million, "but there is no supporting evidence provided and the actual data released in the report strongly suggests that the opposite is true," the USC-Brookings analysis argues.

Go deeper: Hospitals' dog in the surprise billing fight

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