December 2019 Volume 21 Issue 12
Providing Current Information on

Health Insurance Industry Issues and Legislation

New York's Surprise Billing Law, A Cautionary Tale
In 2015, New York passed a surprise billing law that employs "baseball-style" arbitration
to settle payment disputes between healthcare insurers and providers. Each party
submits a proposed dollar amount to the state arbitrator, who chooses one or the
other as the monetary award. The law includes guidance to the arbitrator to consider
the 80th percentile of "billed charges" in their rulings. To date, the average decision has
been to pay 8% above the 80% of billed charges amount. "The New York systems uses
as its payment standard {billed} charges, which we think is wrong and misguided," said
U.S. Senator Maggie Hassan. Her bill proposes a different standard.
Taking the Sting Out of Surprise Bills
Until the federal government or the states pass surprise billing legislation, costly
surprise bills from out-of-network providers for emergency room visits and hospital
admissions will be painful for everyone. But they don't have to be. Utilizing a
combination of technology and tenacity a skilled cost containment company, like
HHC Group, will find a way to cut surprise and other out-of-network bills down to
size. That company will have its skilled negotiators convince providers to accept an
appropriate amount for their services, will access discounts from its PPO partners
and will scrutinize the bills to identify costly overcharges and errors and take the
sting out of those surprise bills.
Premiums, Deductibles Eating Up More of Employees' Incomes
Workers' contributions to their health plan premiums and deductibles continue to
increase faster than their incomes. Over the last 10 years. In 2008, average contributions
exceeded 10% of median income in only 7 states. By 2018, that number had increased
to 42 states and contributions in 16 states surpassed 12% of medium income. The good
news is that rate of the increase slowed significantly between 2016 and 2018 versus the
prior reporting periods.
Generics and Biosimilars Under Attack
More and more generic drugs are being placed on higher formulary tiers significantly
increasing patient copay amounts. This coupled with branded manufacturers offering
rebates and other incentives on their products to limit the reach of new generic
products spells trouble for both new and older generics and new biosimilars. The
number of generics on tier 1 in Medicare D plans fell from 71% in 2011 to 19% in 2019.
It's estimated that the drop increased total patient costs by $6.2 billion for the same
drugs. The Association for Accessible Medicines has proposed a number of potential
solutions to the problem.
Three Star Preferred Provider Program Additions
Jenny Brady
Quiton, VA 23141

South Florida Oncology and
Hematology Consultants, Inc.
Ft. Lauderdale, FL 33313

Health Sleep Center
Carrollton, OH 44615

Thomas McCartney, MD
Columbus, OH 43221

Cornerstone Clinic for Women
Little Rock, AR 77205

Active Healthcare, PA
Jacksonville, FL 32216

Robert A. Jackson DPM
Greensburg, PA 15601

Ocala, FL 34474