America's Benefit Specialist April 2023

projections and the fact that a vast number of submissions were ultimately deemed ineligible. The latter can largely be attributed to the fact that many claims falling under a state’s jurisdiction—or ones that apply to Medicare—are incorrectly going through the federal arbitration process. Another major focal point of Condeluci and Work’s pre sentation was hospital price transparency, or rather the lack thereof. Among the many sobering statistics presented, it was indicated that 85% of hospitals remain non-compliant with the federal requirements to publicly post prices for services and drugs. Perhaps even more troubling, among the 188 hospitals comprising HCA Healthcare, the country’s largest for-profit hospital system, zero were compliant. Mean while, among the Big Three hospital chains—HCA Health care, Ascension and CommonSpirit Health—merely two out of 361 hospitals were following the price-transparency rules. As if this situation wasn’t challenging enough for consum ers of healthcare, many owners of provider networks refuse to share pricing and claims data with plan sponsors and, ulti mately, the plan members—even though Congress recently prohibited “gag clauses” in contracts between a plan sponsor and the owner of a provider network with the express pur pose of ensuring that electronic claims data and negotiated in-network service pricing is available to self-funded plans and their members. Apparently, the network owners are find ing workarounds in the form of other contractual language that upholds the restriction of data. In short, there’s still quite a bit of work needed to ensure the American workforce has more insight into provider charges. It is also readily apparent that some providers are sim ply not adhering to the negotiating process as set forth in the NSA. A cornerstone of the NSA is the 30-day business period during which there would be good-faith negotiations between plans and healthcare providers. In many cases, however, providers have no incentive to engage in good-faith negotiations (they are often so confident they will reach a fa vorable outcome in front of the IDREs) instead holding fast to their billed charges—hence, the exceptionally large volume of disputes headed to the arbitration process, one that is still in its nascent stages and struggling to account for such an unexpectedly voluminous caseload. Meanwhile, it is often the case that the information presented in the arbitration pro cess lacks sufficient credibility and transparency and is not always relevant to the circumstances of the dispute.

The perspective and behavior of healthcare consumers regarding healthcare consumption also bears mentioning. In 2023, the overwhelming majority of Americans are accus tomed to accessing desired information within a matter of seconds. When shopping for healthcare, many often have lit tle incentive to spend considerable time perusing data files, ones that may not be particularly accessible or grounded in proper context, because there is no apparent upfront finan cial savings. After all, their respective health plans are respon sible for the initial costs. But, as has been well-documented, if a self-funded health plan can be spared unnecessarily high costs, its participants win in the long run. Hence, the reason that many employers craft incentive-laden benefit plans. Surely, greater price transparency in the healthcare field is a multifaceted issue with no definitive resolution in sight. But hopefully in the coming years, healthcare consumers will become more enlightened about the cost and quality vari ables associated with medical services while information will be transmitted to them in a more user-friendly fashion. All of which would be instrumental in preventing healthcare costs from spiraling out of control. IT IS ALSO READILY APPARENT THAT SOME PROVIDERS ARE SIMPLY NOT ADHERING TO THE NEGOTIATING PROCESS AS SET FORTH IN THE NSA.

David Ostrowsky serves as a content special ist for The Phia Group, a position in which he generates a wide range of written content for both internal and external functions. A graduate of Brandeis University, David was previously a content specialist for the recruiting company formerly known as WinterWyman. He is also a regular contribu

tor to the Atlanta Jewish Times and has authored multiple books, including his most recent, Pro Sports in 1993 , published by McFarland & Company in 2020.

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