Billing, antitrust exemption changes upend negotiations between insurers and providers

A flurry of recent mandates will completely upend the negotiating table between payers and providers, but how the final contracts will change going forward all depend on enforcement.

Although most negotiations between hospital systems and insurers have been finalized for 2021, Rick Kes, a senior analyst at RSM, said recent mandates around surprise billing, price transparency and the antitrust exemption for health insurers will reverberate throughout the healthcare industry for years to come. In late January, CMS also approved a prior-authorization rule that requires payers to build application programming interfaces between their records and providers’, in a move to speed decisions about whether patient procedures are covered. The changes will phase in during 2023 and 2024.

Kes expects the new laws to accelerate hospitals’ move to value-based arrangements with insurers, and drive investment in consumer-centric digital tools that help individuals compare procedure prices between systems.

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