By Matt Skoufalos
In a recent white paper, Tina Azar, vice president and market leader for global analytics firm EXL Health, reported that one in five medical claims and one in six hospitalizations can include a “surprise bill” or “balance billing” from an out-of-network physician. That these issues might present themselves during emergency care, when a patient may be least able to advocate for themselves, or answer insurance questions; or when receiving services from an ancillary provider at an in-network facility, at which a patient might reasonably believe its providers participate in their health insurance, is challenging enough. Compounding that fact, Azar wrote, is that surprise and balance billing are proving to be among the leading causes of medical debt in America.
That’s per an April 2021 study in the Journal of the American Medical Association, “Frequency and Costs of Out-of-Network Bills for Outpatient Laboratory Services Among Privately Insured Patients,” which reported that “out-of-network outpatient laboratory services were five times more common than out-of-network emergency department visits, and 34 times more common than out-of-network anesthesiology services, and are associated with substantial patient out-of-pocket costs.”
The “No Surprises Act,” embedded within the federal Consolidated Appropriations Act of 2021, is meant to curb this practice, banning surprise bills for most emergency services, out-of-network cost sharing, balance billing for out-of-network providers at an in-network visit, and up-front notice about billing procedures and complaint disputes.
The legislation also requires health care providers to notify their customers, “in clear and understandable language,” whether the provider from which they are seeking services participates in their insurance, the contracted rates and diagnostic codes for the procedure(s) they’re about to undertake, how to find this information if they’re working with an out-of-network provider, and “a good-faith estimate” of both the customer’s and insurer’s shares of their bill, as well as how much they’ve already been billed against their deductible.
In short, the law forces providers to generate and publicize their pricing structures so that customers have a chance to make a more informed decision before consenting to care. For integrated hospital groups, it reflects a significant intersection of challenges related to staffing, revenue cycle work and compliance. In terms of lines of service, however, its impact is likely to be felt most deeply in the delivery of emergency care and medical imaging.
Angie Bush, system director of radiology services at the University of Texas Medical Branch in Galveston, Texas, said she believes the overall challenge of the law involves keeping radiology, still a revenue generator for many health care institutions, from becoming a commodity service.
“It’s going to change everything for us,” Bush said of the new law, “and interventional radiology is going to be hit the worst.”
Bush foresees a number of complications that could arise for radiology directors, revenue cycle teams, and practice administrators, simply as a function of unintended consequences. What happens, for example, when a referring physician orders the wrong exam? What happens when administrators develop a cost estimate, but other medical deductible payments in process have not yet hit the patient’s insurance?
“We could be off on our estimate simply because of what is still pending,” Bush said. “And what happens to radiology workflow when, instead of protocolling studies after the appointment is scheduled, we have to ask physicians to protocol before scheduling just so we can insure the CPT doesn’t change for the payment?”
Beyond all those wrinkles, Bush also described the lengthy process that must be completed before any potential cash prices can be calculated for those requesting them. It starts with determining the patient’s copay – which can change if that person carries insurance and has met their deductible – and even that’s contingent upon the timing of other medical bills that might have been incurred for routine procedures, ranging from laboratory exams to primary care copays.
“If more bills are issued to say that they met their deductible, it’s going to change, and that’s out of my control,” Bush said. “Say they have a $1,000 deductible, but to get that MRI order, they had to see a doctor. Did that doctor send his bills already? Maybe he ordered labs, or a test that was done somewhere else. These other pending payments may change what my estimate will be, not because the cost of my test changes, but because what the patient is liable for varies based on other providers dropping their payments and the insurance company recognizing them.
“All of those bills that that patient paid could contribute to their deductible for the year, but if this person comes straight to imaging, we see that they have a $1,000 deductible,” she said. “If they have a deductible, we have to collect that deductible. If we find out that they met that deductible, then we have to reimburse it.”
“This is an error where a patient normally would be happy that they don’t have to pay as much, but we can only give the cash-pay price based on what is documented in the patient’s insurance at the time,” Bush said.
Quoting a cash-pay price for an interventional radiology (IR) procedure is even more complicated, Bush said, and many facilities are still developing their methodologies for doing so. Her institution is starting by compiling an average cost for the most common IR procedures, then ranking them by complexity, and basing a cash rate on those average costs, including any medications and supplies typically needed for the work. At some point, however, doctors will be left to guess as to whether a procedure for which they’re researching protocols is simple or complex, as best as they can surmise ahead of performing it.
“For MRI, CT and nuclear medicine, the big change is that we’re going to have to protocol that order to ensure that that is going to be the actual CPT code that we’re going to perform,” Bush said. “Currently, radiologists protocol exams for the next day; for a cash-pay rate, they have to protocol it before the cash-pay rate is given. Our rev-cycle would call our reading room assistant; the radiologist has to pull that order up, look at the history, and do the protocoling right then and there, so it will interrupt their reading cycle. They give that information to rev-cycle, and they can give a more accurate cash-pay rate.”
Even if those quotes are one-offs, the process of interrupting reading workflows to address providing them is time-consuming, and potentially yields inaccurate results. Bush pointed out that the copay an imaging facility may collect and what the procedure may cost will not always be the same. When that happens, determining who’s responsible for the difference could become an issue.
“I’m curious how this is going to play out,” she said. “If we over- or under-estimate, that’s considered a hit against this rule. We have to get within a certain percentage or dollar amount of accuracy, and any time we don’t get it, we may be penalized financially as an institution.”
“Our organization is a very strong, lean organization,” Bush said. “Our leaders expect us to look beyond the superficial pain, and get to the root of the cause.”
“If the root of this law is to prevent people from going into debt because of medical expenses, this law isn’t the answer, it’s changing the culture of how we seek care. It’s the Band-Aid; it’s not the root,” she added.
Elyce Wolfgang, director of imaging services at WellSpan Health of York, Pennsylvania, an integrated health care system serving several counties in the south-central region of that state, said that, even as a health care professional herself, she occasionally has a difficult time interpreting her insurance benefits and costs. She hopes the impact of the no-surprises law ultimately will lead to greater pricing transparency for patients overall.
“When you think of someone who has zero health care background and experience, for them to interpret what their insurance actually covers versus in-network, out-of-network; it’s confusing,” Wolfgang said. “That’s where we struggle as a whole. How do we better explain this to people in a way that they can understand it, and it’s easy to understand?”
One of the ways in which Wolfgang believes that medical imaging could be tripped up by the constraints of the bill lies in some of the underlying structure of the industry in 2023. In an effort to maintain competitive pricing while also increasing patient access to services, many imaging institutions rely on teleradiology services for reviewing studies as well as ancillary services provided by specialists like anesthesiologists, which inadvertently could expose patients to out-of-network costs.
“It’s not like we have signage posted in the hospital that if you come in for a CT scan, the radiologist’s report is going to come from a third party,” Wolfgang said. “Obviously, we have credentialing to ensure safety, but you don’t know, as the patient – and even as the health care provider, I wouldn’t even know where to begin to inform the patient – that your test went to an outside radiologist.”
To ease customers into the work of calculating pricing prior to scheduling a service, or to avoid balance billing, facilities like WellSpan are coming up with pricing calculators that patients can use to estimate the anticipated costs of their visits.
“We have a price estimator tool where the patient can log into their chart, get an estimation for their study, and it links in their insurance,” Wolfgang said. “It will give a pretty decent, pretty accurate estimation; what is doesn’t always take into consideration is have you met your deductible yet, and do you have coinsurance. Sometimes it pulls that, and sometimes it doesn’t. That information is only as good as the information the patient provides us.”
Despite attempts to capture accurate information, pricing can fluctuate for any number of reasons. Some studies, like mammograms, may be statutorily covered by insurance under state screening mandates; however, additional imaging that might be needed as a follow-up may not be. Some patients don’t understand the differences among copay, coinsurance, and deductibles, let alone how study pricing is determined; and Wolfgang believes that, beyond any of it, many patients will simply elect to receive care at the facilities where they are most comfortable, regardless of whether it’s the lowest out-of-pocket cost.
“I think the majority of patients are still going to ignore the price tag,” Wolfgang said. “Let’s say I’m familiar with my health system, and the CT that I get here is going to cost me $100 more than if I go somewhere else, but I love my doctors and my experience here. I’m willing to pay a little more out of pocket to stay here than go with another organization.”
“We’re headed in the right direction, but I just don’t think we’re there yet as an imaging industry,” she said. “I think we’re a while away from getting there, wherever ‘there’ may be.”
Dr. Howard P. Forman, MBA, FACR, is a professor of radiology and biomedical imaging, public health (health policy), management, and economics at Yale University. He believes that, although the no-surprises law reflects a greater effort to gain more price transparency overall, that is the responsibility of larger health care institute on the whole, and not specifically of the field of radiology.
“Nobody expects that full transparency will result in a dramatic transformation in anything,” Forman said. “There’s no certainty that it will result in greater positive change; there are even concerns that full transparency will result in higher prices. But we believe that perfect information allows consumers to make better decisions, and it includes both price as well as the value of what they’re buying.”
To Forman, radiologists and practice owners must address both the consumer understanding gap in what services they’re buying when patients contract for them, as well as the options for selecting a practitioner or a facility, and the impacts to care and costs that are conferred with those decisions.
“There are a lot of people that have responsibility here,” he said. “In an ideal world, hospitals could contract for consummate services, and take responsibility for any costs that occur outside of the network that they are selling. If a hospital tells a patient when they roll into the ER that they are in the network, that hospital could figure out how to take responsibility for anyone who is not in network for that person, and then contract with people who are in network.”
“Radiologists are often hospital-based providers,” Forman continues. “If a radiologist is performing services for a hospital that is Company X, and the radiologist is not a provider for Company X, that seems like something that can be figured out ahead of time. Most of the cost of radiology is tied up in the technical component, and hospitals do have the ability to transmit current data on these things.”
As institutions approach questions of price transparency, Forman noted that the federal government, to date, has been more concerned with developing compliance with the law than achieving perfection. He described the attitude around enforcement as one of being “extremely understanding,” and offering plans for remediation rather than assessing financial and legal penalties as an incentive to getting everyone onboard. Once enforcement actions shift, however, and the consequences for failing to comply with the rules become more significant, facilities could be subjected to corrective action plans on strict timelines, with automatic fines incurred.
“No one’s saying that they have to be perfect; they just have to comply,” Forman said. “We all have to play our part.”
