Balanced Regulatory Environment: A Key Component to Unlocking the Value of Specialty Bill Review

Without the use of Specialty Bill Review (SBR), payers risk paying for errors or abuses created by providers with problematic billing practices. The regulatory climate in each state is a key component to ensuring fair and reasonable payment of medical bills especially in non-fee schedule states 

Our team of regulatory professionals, including lobbyists and government relations experts, work tirelessly to educate legislators and regulators. We collaborate with trade associations, write white papers, attend conferences, and testify at committee hearings. These efforts are aimed at creating a more predictable and fair regulatory environment. 

Our lobbying and government relations efforts have yielded significant successes over the years, such as successfully implementing restrictions on balance billing in New Jersey that provides explicit protection to patients. We have also advocated for statutes of limitations on medical fee disputes in various states, benefiting both our customers and the broader industry.  

Although legislative advocacy is our specialty, there are times that it can be challenging.  

3 Reasons Specialty Bill Review May Not be Available in Some States

1. Lack of Data: In some states, the lack of reliable data on provider charges and accepted payments makes it difficult to implement SBR effectively. Without this critical information, our ability to make accurate recommendations is compromised.
2. Unfavorable Laws: Certain states have laws that leave little room for SBR to operate effectively. These laws either have well-defined fee schedules or favor providers to an extent that cost containment becomes challenging. In such environments, SBR may not offer significant value to our customers.
3. Regulatory Hostility: In states where the regulatory environment is more favorable to providers, offering SBR services may not be feasible. These states often have laws that discourage cost containment measures, making it impractical for SBR to function effectively.

Key Issues in Top States 

Florida has recently undergone significant changes, particularly in its provider and hospital manuals. The transition from an inpatient structure to a per diem structure has brought new challenges and opportunities for SBR. These changes narrow the scope for SBR but also highlight the need for adaptive strategies. 

New Jersey is another state where regulatory changes are in the spotlight. Enlyte is actively involved in lobbying for incremental policy changes that improve the operational landscape for both payers and providers. One of our key initiatives is to introduce a statute of limitations for medical fee disputes, ensuring timely resolution of claims. 

Don't let unfavorable laws or a lack of data hold you back—Connect with our team of regulatory professionals today to learn how Specialty Bill Review can benefit you and ensure fair, efficient payment practices in your state.