What pleases providers does not always please insurers.
Another example of that fact is a little-noticed provision in a pending bipartisan managed-care reform bill introduced in the House. The provision calls for development of a standardized explanation of benefits form. All third-party healthcare payers would be required to send the forms to providers and patients after processing and paying claims. The forms would explain what was paid, what wasn't covered and why.
The provision gives providers yet another reason to happily support the bipartisan bill offered by Reps. John Dingell (D-Mich.), Greg Ganske (R-Iowa) and Charlie Norwood (R-Ga.).
"It would make the process simpler, more streamlined, and easier to get paid," said Carmela Coyle, the American Hospital Association's senior vice president for policy.
To date, the bill, including the standardized form provision, has received enthusiastic endorsements from the American Academy of Family Physicians, the American Medical Association and Families USA, a consumer advocacy group.
Norwood said his interest in a standardized form was inspired by his experience as a dentist in Augusta, Ga.
"One of the most expensive administrative problems people have is they have to hire people to figure out all these different forms," he said.
"You have to have a clear explanation of a claims denial," said Mary Elizabeth Roth, M.D., a member of the Michigan Academy of Family Physicians, a state affiliate of the AAFP. "Insurance companies don't openly state why they aren't paying for something, and the American public is frustrated with that because they don't know if or how they can appeal those denials," she said.
The provision was the brainchild of Rep. Tom Coburn (R-Okla.), who was a family physician before his election to Congress. Norwood said Coburn included the provision in a consensus proposal that failed earlier this year.
Norwood and Ganske worked on that consensus measure, but frustration with the Republican leadership's glacial pace led them to work with Dingell, a liberal Democrat.
The bipartisan managed-care reform bill gained the support of at least 20 Republicans before the congressional recess began Aug. 6. But Republicans are forging ahead with another bill.
Coburn is working with Rep. John Shadegg (R-Ariz.) on the Republican draft managed-care bill, which would require the use of a standardized explanation of benefits.
The final version of the House GOP bill is expected this week, so it's unclear how the measure would address the development of such a form.
Consumer advocates said a standardized form is a good idea.
"A better-informed consumer is the key to a better marketplace," said Gail Shearer, director of health policy analysis for Consumers Union.
However, insurers question the value of the provision.
Mohit Ghose, a spokesman for the American Association of Health Plans, said the industry embraces simplification but opposes government mandates. He said mandates stifle innovation because people worry about "staying within the bounds of the mandate."
But Roth said, "Insurance companies make money by sitting on your premium, so they're not in a hurry to get payments out."
Insurers also question whether such a provision would conflict with the Health Insurance Portability and Accountability Act of 1996.
That law featured an "administrative simplification" section, which established standards for the electronic transfer of healthcare information. The section called for the development of an electronic claims form for hospitals and physicians, and an electronic explanation of benefits.
HCFA issued proposed regulations on part of the section last year, and final regulations are due this fall. More proposed regulations involving the rest of the section are expected early next year.
Kathleen Fyffe, federal regulatory director for the Health Insurance Association of America, said "We endorse the idea of a national standard claims form and explanation of benefits, but it's already being done."