Challenges to Current Practice – Update for New Jersey Neurosurgeons

Marc Arginteanu, MD, FACS

Past President of NJNS

In May 2015, an out-of-network reform bill was introduced by Assemblyman Craig Coughlin, Assemblyman Troy Singleton, Assemblyman Gary Schaer and companion bill S-20, by Senator Joe Vitale.The bill’s sponsors stated: “We’ve all seen or heard of horror stories from folks who’ve gotten surprise bills when they’ve gotten medical procedures.”

The most onerous provisions in the bill would:

  • Limit how much out-of-network hospitals and doctors can charge for their services in New Jersey.

For institutions, the maximum payment would be restricted to the “lowest in-network deductible (plan).  No solutions should come at the expense of eliminating out-of-network options for patients and a provider’s ability to negotiate fair contracts with insurance carriers. This bill removes the leverage for providers to negotiate fair in-network rates with insurers by creating a system whereby insurance companies can tie up every single claim  in an arbitration system.

  • Create a binding baseball arbitration process.

An arbitration model based on a win/lose scheme to settle claims disputes would fail to take into account the complexity and patient variation specifics of any and all medical procedures. Language to allow ERISA plans to opt in to the arbitration system, while prohibiting balance billing by the provider will result in chronic underpayment to providers by these plans.

This is an insurance favored measure that would promote narrow networks and eliminate flexibility all while attempting to limit provider reimbursement rates and control fees. We need to address those in-network problems rather than vilifying the small number of providers who are out-of-network.

National headwinds are also a concern.  ObamaCare failures in Colorado have recently spurred an unpleasant backlash.  More than half a million cancellations of health care exchange plans  between 2013 and the end of the year are expected.  Premium increases of about 12 percent are expected on the remainder.  Liberals in Colarado are mobilizing to replace ObamaCare with a single-payer system.  ColoradoCare may  be on the 2016 ballot to replace private insurance with health care funded by taxation alone. Fortunately, the initiative and referendum process is not an option in New Jersey.