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Becker’s Healthcare Podcast
Navigating the No Surprises Act and the Texas Medical Association Appeal
00:13:30
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- [00:00]
A
Hello everyone. This is Erica Spicer Mason with Becker's Healthcare. Thank you so much for tuning into the Becker's Healthcare podcast series. So today we're going to talk about the no Surprises act and the Texas Medical association appeal. And joining me for this important conversation is Patrick Veliki, Chief External Affairs Officer at Halo, Maryland. Patrick, welcome to the podcast. Thank you for being with Beckers today.
- [00:22]
B
Thanks for having me here, Erica.
- [00:23]
A
Oh, so glad to have you. And before we get into the conversation, I wanted to see if you'd like to share a little bit more about yourself, your role, whatever you think is helpful for our listeners to know.
- [00:31]
B
Yeah, thanks. So I joined Halo MD very recently, actually only about two and a half months ago, but I got my start on Capitol Hill, worked in both the U.S. senate and the U.S. house handling policy priorities for both a 30 year member of the Senate and a freshman member of the House. So have some experience on both sides of the Capitol building. To kind of start out, my experience worked as internal government affairs support for two major payers, Humana and then Anthem, which is now elevance, as well as for the Federation American Hospitals, major trade association for the hospitals, and most recently for Envision Healthcare, one of the largest multi state, multi specialty medical groups. So I like to say the only part of the healthcare industry I haven't worked in is probably pharma and med device, but I've sat on just about every side of the table when it comes to health policy.
- [01:22]
A
Excellent. Well, Patrick, it's great to learn more about you and I think your policy background is really going to be helpful for our listeners as we unpack some elements of the no Surprises act and where this intersects with the Texas Medical Association. And so let's go ahead and start there. We're seeing a lot of headlines about how the Texas Medical Association's legal challenges have really reshaped how the no Surprises act is being implemented. So what do you see as the most significant changes that CFOs and revenue cycle leaders need to understand about that shift or just in general? What do you think they should know?
- [01:55]
B
Yeah. So it's really interesting and you're absolutely right. The TMA challenges, and there have been four of them to this point, not, not including appeals, have really change the implementation pathway of the nsa. What's a little bit frustrating about that is that it's changed it essentially to what it should have been in the first place. Right. There was really a pretty significant diversion between congressional intent and the statutory language and what the original implementing regulations sort of spelled out. So it is a little frustrating to have, you know, the TMA and the provider community go through this long and at least for, you know, the party's expensive process just to get to where things should have been in the first place, but very, very encouraging that that's where we are headed and ending up. I think really what's important for possible CFOs is understanding, I think really just how underutilized the IDR process is on the hospital side. There are a whole lot more opportunities to engage in arbitration than I think most hospitals realize. You know, the way the NSA works, it's very focused on ensuring that patients really aren't negatively impacted when they need care or couldn't have reasonably to know the network status of the provider providing their care. So when you think about that from a hospital perspective, mostly it's emergency medicine, right. Where neither the facility nor the providers are in network, that patient is protected, and all of that care is treated as emergency care. And the hospital can go through an arbitration process if they need to sort of seek fair reimbursement without getting too deep in the weeds. There are a whole lot more opportunities on the hospital side, mostly based on definitional differences between what hospitals consider to be medically stable versus what the NSA considers to be stable. But the point is, I think a lot of facilities take a narrower view of what's eligible for the arbitration process and could really be well served by getting to understand the process a little bit better and seeing whether or not there's money that they're leaving on the table to support revenue and support ongoing function.
- [03:59]
A
Yeah. Such important points you're raising. Thank you, Patrick. So beyond the revenue piece, I want to go a little bit deeper about what some of the latest changes around arbitration and qualifying payment amounts mean for healthcare. What are some of those implications?
- [04:13]
B
Yeah. So without going all the way back through the whole history, you know, we really started in a place where the payer was going to get to set the rate, Right. The qpa, that qualifying payment amount, which is supposed to be the median and network rate, that was pretty much the take it or leave offer that we were looking at under the original implementation of the nsa. And where we are today is that that's very much not the case. The QPA is one factor that is considered among many, and providers and facilities can really make a compelling case to an arbiter around a whole bunch of other considerations that has led to meaningful success in the arbitration space. On the provider and facility side, the latest public use files from CMS show roughly 80% PL success rate on the provider side in arbitration. So it's very, it's very achievable. It's not as stacked toward the payers as a lot of us were afraid it would be in the early days. So really it's worth, like I said, examining whether there's an opportunity on that facility side and taking advantage of it if there is.
- [05:21]
A
Yeah. Thanks, Patrick. And so with some of those shifts in mind, how do you see them affecting payment disputes and overall reimbursements for hospitals? You just touched on some success like the 80% rate. But bigger picture, you know, what are you seeing and how is this trickling down to patient and patient experience as well?
- [05:38]
B
Yeah, so it's really important. Hospitals have faced rate compression and challenges to sustainability of operations for decades, but some of those challenges are even more acute right now. You look at things like the implementation of the one big beautiful Bill act and some of the impacts that that could have on coverage. You look at changes to outpatient prospective payment rules and even Medicare for some fee schedule rules that, you know, the final rule for the Medicare fee schedule just came out last Friday. There are going to be pressures on facilities either through reductions in volumes or increases in uncompensated care or from additional subsidy ask as contracted physicians try to deal with some of the reductions in reimbursements that they'll be receiving under the fee schedule. So it's going to be harder and harder for facilities to make up uncompensated care and lost revenues through volume. They're going to have to get smarter about structural changes to the way that they operate and finding low cost ways to ensure that revenues and reimbursement are greater than operational costs. You look especially at rural facilities. Every eight years, the Government Accountability Office, the GAO releases a study or a report on the health of rural facilities. And the last three reports in a row have showed more rural facility closures than the previous report. Every year more and more rural facilities close. That's a bit of a preview for some of the challenges that are going to be facing non rural facilities. Whereas again, bad payer mix and the acute unsustainability of some rates start to really impact bottom lines.
- [07:31]
A
Yeah. So interesting. It's interesting how what rural facilities are facing can kind of preview what's to come for others, as you just mentioned, Patrick. And it sounds like there are some key infrastructural changes that organizations are going to have to make to stay not only viable, but hopefully, you know, see growth as well, so as you look ahead, as we're facing more changes and adjustments with the NSA and just challenges in general, what steps do you think finance leaders should be taking right now to stay compliant while also safeguarding revenue in this environment?
- [08:02]
B
Yeah, so compliance is, is a great sort of starting point as, as you mentioned. And what's I think really important is obviously facilities and provider groups ought to be looking at their own compliance both within the NSA and other areas. But they should also be scrutinizing compliance of payers and other vendors that they're, they're working with. There's a very, very complicated compliance landscape that also creates some perverse incentives to not comply. Really having an understanding of not just your own responsibilities as far as compliance is concerned, but the responsibilities of the other parties you're engaging with is going to be necessary to ensure that one, you're not inadvertently open to the liability of those that you contract with, but that you aren't being taken advantage of through non compliant practices of payers or. So, yeah, compliance really is key and it's even more complicated than it's ever been. So that's certainly one important step. The other is really making sure that you understand the current regulatory landscape. There are massive changes happening next year and the year after and a lot of them are knowable. And even if you can't solve the problem, at least knowing what it is so that you can adjust financially, maybe you know, deferring an investment that you were going to make next year to ensure that you've got the cash flow and reserves to cover day to day. Just understanding what's coming down the pike and what might be disrupting your financial projections can go a long way to ensuring that you don't get caught by surprise and have to make decisions that you didn't have the foresight to make, you know, better decisions before. So really that planning, that understanding and making those changes while you've got time instead of when you're forced to do it?
- [10:05]
A
Yeah, absolutely. And staying on top of all of the changes, I'm sure is no easy feat for organizations. Do you have any quick best practices or anything that you've seen organizations do well to stay up to date?
- [10:15]
B
Yeah. You know, fortunately hospitals have some really strong trade associations who do great jobs educating their members. Make sure you're involved with your, your associations both at the state and the level. That can go a long way toward just that initial understanding. But make sure you contract with good vendors too. Right. Don't just set it and forget it. You do have to make sure that the vendors that you're using are right for you and that they are on top of their compliance responsibilities. And then things like understanding whether there are opportunities for you in the IDR space. Right. Like I said at the top, there are facilities who are leaving revenue on the table because they don't even realize that that IDR is an option for them and can really one, not just ensure fair revenue recovery for services that have been provided, but two, as was originally intended, can really be a great opportunity to obtain sustainable long term network arrangements with payers utilizing the arbitration process to drive toward economic equilibrium and find that sort of fair market rate and is really what the NSA was intended to do in the first place on the back end. So I'm hopeful we start to see more of that take place. We unfortunately haven't seen a whole lot of that yet, but really IDR ought to be a tool toward in network arrangements.
- [11:42]
A
So. Interesting. Patrick, this has been really helpful. I really appreciate the practical steps and considerations you just outlined too. Is there anything else that we didn't touch on or any final thoughts that you wanted to leave our listeners with?
- [11:53]
B
Yeah, you know, there's a lot of changes like I mentioned on potential threats to facilities and sustainability, but there are also a lot of changes just around the corner that could be very, very positive for facilities, especially within the IDR space. There's some pending rulemaking that we're expecting before the end of this year that can really improve the ability to get through the IDR process in a cost effective, streamlined way. We're gonna have to wait for those final regulations to see exactly what that looks like. And you know, the devil may always be in the details, but there's lots of opportunity as long as you're aware of of the challenges along with them. So I don't want to, you know, be a Debbie Downer on the whole thing and just talk about some of these challenges facing facilities. There really are opportunities to meet those challenges before they become, you know, impediments and several opportunities just around the corner to stabilize facilities and really continue providing that important care in the communities that they serve.
- [12:55]
A
Yeah. Well, I appreciate you ending on an a note of opportunities because I think that's so important to highlight, Patrick, and I'd be interested to see where this conversation would land a year from now. What will we be talking about? How will things have developed? So really appreciate again your, your perspective as someone who's worked in healthcare policy for so long. I think it's been really illuminating, not just for me, but for our listeners, too. Thank you so much.
- [13:17]
B
Thank you.
- [13:17]
A
And of course, we'd also like to thank our podcast sponsor today, Halo md. Listeners, be sure to tune into more podcasts from Becker's Healthcare by visiting our podcast page@beckershospitalreview.com.