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ADVOCACY SPOTLIGHT


needed to find in-network providers if the provider in question is out-of- network, the estimate submitted by the provider with a presentation of the health plan’s and the patient’s finan- cial responsibilities and more. This information must be sent on a similar timeline to the one described above. Additionally, health plans will be required to update their


list of in-


The IDR process is modeled after the one used in Major League Base- ball: each party submits one final offer and supporting information, the arbiter selects one of those options, and the result is binding on the par- ties. The loser pays the cost of arbi- tration. The law instructs what the arbiter can and cannot consider. The arbiter must consider a market-based median in-network rate for the ser- vice; the provider’s training and expe- rience; the complexity of care and patient’s acuity; the facility’s scope of services, case mix and teaching status; demonstrations of good faith efforts to resolve the dispute or lack thereof; prior contracted rates; and other information brought forward by the parties. The arbiter cannot con- sider provider charges or Medicare or Medicaid rates. The law specifies that the arbi- tration process will be concluded within 30 days. Additionally, there is a 90-day cooling off period that pre- vents the party that initiated arbitra- tion from starting another IDR pro-


24 ASC FOCUS MARCH 2021 | ascfocus.org


cess for the same items or services following the arbiter’s decision.


New Obligations for Providers and Plans Beginning January 1, 2022, providers will be required to verify a patient’s coverage and provide information to a patient’s health plan or the patient themself in the event they are unin- sured. This information includes codes and the total expected charges, inc- luding expected ancillary services. Exactly when the information must be provided to the patient or plan var- ies. When a service is scheduled more than 10 business days in advance, the information must be transmitted within three business days. For ser- vices scheduled at least three busi- ness days in advance, the information must be transmitted within one busi- ness day.


Similarly, health plans will be required to send patients an “Advanced Explanation of Benefits.” The notice must indicate whether the provider and facility are in-network, the contracted rate or the information


network providers every 90 days and develop a process for coordinating with providers to keep this informa- tion current. This information will be accessible by patients online and over the phone. A patient who relies on a health plan’s inaccurate provider directory will be responsible for only the in-network cost-sharing amount if they can provide documentation of the incorrect information. Under the law, health plans will be required to create and maintain an internet price comparison tool. The text of the law specifies the fac- tors that must be included, which are similar to those on Medicare’s Proce- dure Price Lookup Tool, but does not proscribe how that information is to be presented.


Results of Advocacy As a result of this law, patients are likely to be more aware of which care providers are in-network than before and will be able to review cost infor- mation for providers when considering a procedure. This should create more awareness among patients enrolled in commercial health plans about the high value care that ASCs provide. The law’s final language designed to prohibit surprise medical bills and resolve billing disputes went through many iterations before


becoming


law, but even the earliest proposals worked to remove patients from the middle of billing disputes. For the last two years, ASCA was part of a stake- holder group that worked to create a balance between the impact on pro- viders and plans.


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