Anesthesia Under Assault: New Roadblocks to Reimbursement
Summary
Anesthesia practices increasingly face new and more robust strategies by some health insurers to suppress payments.
In a follow-up to last week's alert, we intend to focus once more on ways in which anesthesia providers are encountering new challenges to getting paid. We have noted with increasing concern tactics being employed by some of healthcare's heavy hitters to delay, decrease and deny payment for services rendered. We've all seen claims rejected due to honest errors committed by a payer or other party, but what we're seeing now is a growing trend on the part of some insurers to reject large numbers of claims for inexplicable reasons.
Stop—Do Not Pass Go
As a case in point, one payer has begun the practice of automatically denying payment for large blocks of claims unless and until "additional information" is sent. Typically, this involves the post-claim submission of the anesthesia record or the pre-anesthesia assessment. The point here is that this pattern of requiring additional information is arbitrary in that there does not seem to be an underlying rationale for the request in most cases. In other words, the payer seems to be adding an additional roadblock to obtaining reimbursement on the front end. Once you get past that hurdle, there are often other surprises in store, such as "claim not on file," "record never received," which may ultimately lead to "untimely filing." Even if you receive notice of payment, the payment will sometimes get "lost in the mail."
The Proof is in the Pudding
Even more disturbing is the trend we are seeing in connection to one large national payer. Upon analyzing over a year's worth of payment data, we have been able to determine that from January to July of 2018, the average "unpaid claims" rate for all states relative to this carrier was consistently at three percent. Beginning in August of that year, the rate rose to, and continued at, four percent. In the last two months of 2018, the rate inched up to five percent. Then, in January of this year, this carrier's national average unpaid rate rose to nine percent, followed by 15 percent in February, and a whopping 24 percent in March. Some states saw their unpaid claim rates more than double from February to March. This data supports our contention that anesthesia providers are facing greater difficulties in obtaining payments—at least as it concerns certain health plans.
On the Outs
Another issue involves the practice of singling out groups that are currently outside of the payer's network. These non-participating providers, in some cases, are finding their once reasonable reimbursement rates suddenly and severely slashed. As an example, a particular carrier had historically paid one of our out-of-network groups a satisfactory percentage of charges upon appeal. Now, that same carrier is paying at 110 percent of Medicare rates. This translates to a dramatic drop-off in revenue for the group in question, and we fear other out-of-network groups will be similarly targeted. This happened to be in a state that recently passed a balance billing law that prohibits "surprise medical bills" being sent to the patient by non-par providers, as discussed in last week's article.
It would appear that such tactics are meant to force groups to contract with the payer, but what does the group do when the contracted rates are unreasonably low? Must they choose between near-Medicare level payments on the one hand and unsatisfactory contracted rates on the other, or is there a door number three? In the section below, we will provide possible solutions to this issue and to the other concerns previously addressed hereinabove.
Resolute in Our Response
Though it is our desire to foster good relations with all healthcare insurers, we must recognize that there are certain payers that are now presenting us with significant challenges. This is the new reality. That does not, however, mean that we need to acquiesce and accept. Where we have evidence of unfair or unreasonable tactics being used for the single purpose of curtailing payments to anesthesia providers, such providers must push back. Here are two ways you can do that:
- The leadership of each anesthesia group should work directly with their state Insurance Department, Justice Department, and anesthesiology advocacy organization to bring pressure to bear on insurance companies that engage in unreasonable tactics to suppress payments. We continue to do what we can on our end—writing letters and contacting officials—but we need your voices added to this conversation. It is the responsibility of all to join in this campaign.
- Anesthesia group leaders should contact the American Society of Anesthesiologists. Urge them to strongly lobby the appropriate officials in Washington, D.C. to immediately investigate questionable tactics being employed by health plans to avoid the fair payment for services provided to patients by anesthesiologists and anesthetists.
While these measures are undertaken by you on the state and national level, we—as your business partners—will continue to look for ways to increase levels of reimbursement from recalcitrant payers to the extent we can. We remain confident that fairness will ultimately prevail. If you have questions or recommendations regarding this important issue, we invite you to contact your client account executive.