"The most effective way to address the NSA legislation, particularly elements of the IDR process, is to adopt a 'pure' RBP plan. This structure doesn't depend on a network's ability to negotiate a price for a specific provider in a specific location for specific services. There are no in- or out-of-network claims, nor is there any determination of a median in-network rate. Based on the guidance received to date, pure RBP appears to avoid the NSA IDR process -- because there are no contracted rates."   MORE >>

"The regulations estimated that 17,000 claims per year would be subject to the arbitration process established by the law to settle disputes over out-of-network payments from insurers to providers. But ... that number would be exceeded by a wide margin if even a tiny fraction of the projected 12 million claims ends up in the process formally known as independent dispute resolution (IDR)."   MORE >>

"The [ACA] made preventive health care such as mammograms and colonoscopies free of charge to patients without cost sharing. But there is wiggle room about when a procedure was done for screening purposes, versus for a diagnosis. And often the doctors and hospitals are the ones who decide when those categories shift and a patient can be charged -- but those decisions often are debatable."   MORE >>

"Pharmacists and drug wholesalers can import prescription medicines from Canada for up to two years as part of state programs aimed at bringing down drug costs ... The guidance lays out requirements for importing drugs from wholesalers licensed by Canadian regulators and for testing and labeling the drugs. It excludes some controlled substances, biological products and infused drugs."   MORE >>

"It's obvious why public health spending would surge during a pandemic. But what could justify the nearly $65 billion increase in private insurers' overhead? And how is it that two thirds of that increase came from private insurers' subcontracts with Medicare and Medicaid?"   MORE >>

"Due to lack of Supreme Court guidance on these issues, it is still not clear the extent to which particular arbitration provisions may apply to ERISA fiduciary breach claims. However, several Circuit Courts of Appeal have now weighed in and a bill called the Employee and Retiree Access to Justice Act has been introduced in the House and Senate ( HR 7740 and S 4219 ) with the express purpose of making predispute and nonconsensual post-dispute arbitration clauses unenforceable. What is a plan sponsor favoring arbitration to do?"   MORE >>