February 14, 2019

ACR Supports AMA Joint Principles on Out-Of-Network Billing

The American College of Radiology (ACR) has joined over 100 medical groups and specialty physician societies to support the American Medical Association’s (AMA’s) recent statement of joint principles on unanticipated out-of-network billing.

The AMA letter was directed to the chairs and ranking members of congressional committees that will consider expected federal legislation addressing the issue. The groups collectively urged them to consider the importance of insurer accountability, limits on patient responsibility, transparency and other issues, as they consider possible legislative remedies for patients who are subjected to costly out-of-network bills.

The groups stressed that patients should only be responsible for in-network, cost-sharing payment rates after receiving care that results in unanticipated medical bills. Physicians should be provided with direct payment/assignment of benefits from the insurer to avoid having patients caught in the middle of insurer/provider disputes about their uncovered care.

The letter called for strong federal and state government oversight of overly narrow provider networks that exacerbate the insurance coverage gap problem.

It called for robust network adequacy standards that should include, among other requirements, an adequate physician-to-patient ratio for emergency physicians, hospital-based physicians, and on-call specialists and subspecialists. Moreover, it recommended that any federal legislation to address unanticipated out-of-network bills should also apply to ERISA (self-funded) insurance plans.

The provider stakeholders emphasized that payment caps should be avoided for physicians who treat out-of-network patients. But, when they are used, such guidelines or limits on out-of-network provider payments should reflect actual charge data and not a percentage of Medicare rates, which have become increasingly inadequate for covering overhead costs.

To expedite conflict resolution, the AMA and its co-signatories recommended legislative provisions for mediation or a sequential alternative dispute resolution (ADR) process for those circumstances where the minimum payment standard is insufficient.