CAP: Protect Patients from Surprise Bills, Preserve Access to Specialty Physicians

  • 22-MAY-2019

  • WASHINGTON, DC

Washington — The College of American Pathologists (CAP) supports congressional action to protect patients from receiving surprise out-of-network bills, which often lead to financial and emotional stress.

Unfortunately, several prominent legislative proposals to address this important issue are wholly inadequate and unbalanced. As such, the CAP calls on Congress to pass legislation that will hold patients harmless, require network adequacy standards for health insurers, establish a fair reimbursement formula for services provided, and create an arbitration process that denies insurers the ability to dictate payment and, consequently, care provided to patients. These elements are a necessary part of the holistic solution required to address the problem of surprise billing.

While all congressional proposals hold patients harmless from a surprise bill, none include network adequacy requirements. Narrow networks benefit insurers. It allows insurance companies to shift the cost of care to the patient. Robust and adequate networks will reduce the number of surprise bills, which are a result of care provided by an out-of-network provider.

Further, several congressional proposals mandate that providers be paid median in-network rates. This policy, if enacted, would give large insurance companies the ability to set payment rates and eliminate the economic incentive for an insurer to negotiate a contract with a provider. As a result, insurers will be able to unilaterally determine the value of physician services and subsume the physician component of hospital care within its own financial, and, potentially, operational control. That is, yet again, a solution that will only benefit the health insurance industry to the detriment of patients and their doctors.

Payment rates to physicians from private payors should reflect the market value of the service based on charges and commercial payments for the service for each geographic area where the service is provided. Using independent databases, such as FAIR Health Inc, can help inform any payment formula.

The CAP calls on Congress to pass commonsense legislation to address the issue of surprise bills that protects patients from financial risk of out-of-network bills, ensures the financial viability of the health care delivery system, and preserves patient access to physician specialists. The CAP looks forward to supporting legislation that includes these core provisions.

About the College of American Pathologists

As the world's largest organization of board-certified pathologists and leading provider of laboratory accreditation and proficiency testing programs, the College of American Pathologists (CAP) serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide. For more information, visit yourpathologist.org to watch pathologists at work and see the stories of the patients who trust them with their care. Read the 2018 CAP Annual Report at CAP.ORG.