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What's happening in the last week of the year?

Surprise Bill for "out of network" Services

December 22, 2020, Congress passed a government funding deal, which includes a long-awaited federal fix for "surprise billing." Most of the new requirements take effect with plan years beginning January 1, 2022

The new law ensures that patients receiving services in a hospital ED, or standalone ED

  • Must assume the same cost-sharing responsibility for such services, regardless of whether the provider is in-network.

  • Receive credit towards any applicable in-network deductible or out-of-pocket maximums for these payments.

Providers and payers will be able to resolve payment disputes through either negotiation between the parties or an independent dispute resolution ("IDR") process to be developed by the Departments of Health and Human Services and Labor and Treasury.

Keep this in mind during payer contract renegotiation.

Price Transparency

The ruling is in, and hospitals must publish their pricing using the following method:

  • A machine-readable file that contains standard charges for all charges and services at the hospital, including gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.

  • A consumer-friendly display of at least 300 shoppable services can be scheduled in advance, including plain-language descriptions in a searchable format. This section must also provide gross and discounted cash prices, payer-specific charges, and de-identified minimum and maximum negotiated charges.

I notice a large for-profit chain put together a great website allowing the patient to search for their estimate based on the service line and insurance. If the patient is out of network or does not have insurance, you need to call.

The initial goal that hospitals will release their chargemaster is not happening but a significant step for the patient to understand their cost for services.

Another comment that I saw from a healthcare organization disputing the price transparency was

"it will be costly for them to prepare the information required to comply with the new rules. Doing so, they said in their lawsuit, would necessitate spreadsheets with hundreds of thousands of columns, so large that they could crash most standard computer systems."

I hope a spreadsheet does not crash computer systems. It would be time to get a new IT leader if that is the case.

Private Equity (PE) taking over healthcare in 2021?

JP Morgan's virtual event is coming up in January, and everyone has their eyes on the healthcare sector. Healthcare ETF did well in 2020, but here is the key for PE firms, in my opinion.

  • All about "digital" health companies focused on specialty service lines.

  • Anything related to "home care" and "senior care."

  • The combination of digital and healthcare service offerings outside of the brick and mortar is the winning investment combination for PE firms.

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