The Texas Ambulatory Surgery Center Society has announced its support of a bill which would require managed care plans in the state to use "usual and customary" charges based on the 85th percentile of FAIR Health's outpatient rates database for out-of-network facility services.
HB 2697, sponsored by Representatives John Smithee and Craig Eiland, passed out of the Texas House Insurance Committee on May 4.
"The Texas Ambulatory Surgery Center Society applauds the efforts of Chairman John Smithee and Vice Chairman Craig Eiland of the House Insurance Committee to give Texas patients choices in their healthcare facilities, said TASCS President Jill Sluder in a news release. "Providing managed care plans with usual and customary guidelines for out-of-network facility payments will result in lower balance bills and ensure that patients have a choice in facilities and providers when purchasing a preferred provider organization plan."
TASCS also said basing the usual and customary charges on a percentage of the new FAIR Health database will result in fair and accurate reimbursement rates.
According to comments from Ms. Sluder, consumers purchase PPO plans with the expectation that they will have out-of-network facilities and providers available to them. Managed care plans which use "maximum allowables" or "allowables" instead of usual and customary rates for calculating rates create situations in which patients are stuck with a higher balance bill to cover the charges or force ASCs to not offer out-of-network services if they hope to cover their costs. In many situations, the out-of-network benefit is an illusory benefit because the insured and/or the employer has paid extra for the out-of-network benefit by purchasing a PPO product rather than an HMO product but the insured cannot afford to use the out-of-network benefits.
"HB 2697 will mean that out-of-network benefits in Texas once again are meaningful to Texas patients," she said.
Joseph Zasa, co-founder and managing partner of ASD Management, which operates ASCs in Texas, echoes Ms. Sluder's sentiments.
"We believe this bill to be extraordinarily important because Blue Cross, and other payors following its strategy, made the decision to put in what we believe to be unreasonable out-of-network fees which essentially mandate everybody contract with them," says Ms. Zasa. "This makes it very difficult to negotiate for centers, like ours, that are in-network.
"We believe it's necessary to move this through the legislative branch to allow centers to receive fair pricing for procedures," he says. "While we encourage negotiating with payors and being in-network, it's gotten to the point where it's unwieldy and unfeasible for many facilities to basically be told what their reimbursement is going to be."
Learn more about the Texas Ambulatory Surgery Center Society.
Learn more about ASD Management.
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