Get in My Network
There are two main avenues to approach out-of-network pricing negotiations: market-based benchmarking and arbitration.
While the consensus is to put policies in place to remove the patient from the process, the contrast between these two solutions has positioned particular stakeholders against each other.
The newest strategy of hospitals and doctors includes a targeted television ad running in the Washington, D.C. metro area asserting that benchmarking is government-controlled price setting. The ad, spearheaded by the organization Doctor Patient Unity, depicts a situation in which ER staff role into a dark, empty emergency room and are therefore unable to deliver treatment or care.
The narrative echoes the organization’s stated goal: focusing on protecting the doctor-patient relationship and limiting the influence of insurance companies, who they insinuate are responsible for the empty ER in the video because of their ability to influence how rates are set through mechanisms like canceling or failing to renew hospital contracts. Doctor Patient Unity also implies that providers are the losers in a benchmarking situation, as rate setting will drive down in-network reimbursements and ultimately lead to hospital closures and doctor shortages.
In reality, a benchmark would work differently. All health insurance plans would reimburse an out-of-network provider or facility a dollar amount based on median rates negotiated between insurers and providers from a particular geographic area. Providers would then receive local, market-based payments for their services. Depending on the design, benchmark rates could lower, or at least put pressure, on commercial health prices by encouraging providers to come in-network.
We are following the multiple proposals from Congress to address unfair billing structures.