Doctors vs. State of Alaska and Lower-48 insurers: Lawsuit filed over ’80th percentile rule’


In 2004, Alaska introduced a regulatory measure known as the “80th Percentile Rule,” requiring health insurers to reimburse medical providers at least up to the 80th percentile of billed charges within the same geographical area. However, this rule is set to be repealed by the Alaska Division of Insurance on Jan. 1.

A consortium of medical providers, representing a significant portion of the healthcare community, has taken legal action against the state in an effort to preserve this rule. Their argument says that without it, insurers will refuse to negotiate with providers and could attempt to coerce providers into joining insurance networks.

“After months of attempting to communicate with the Alaska Division of Insurance on the dangers of repealing the 80th Percentile Rule without a replacement, we have reluctantly filed suit to protect the countless Alaska families, workers and patients impacted by this misguided regulatory repeal. Every downstream result of abolishing the 80th percentile rule and its consumer protections means less access to care, fewer doctors to see, bigger bills for patients, and the return of the predatory insurance practices that the rule successfully worked to eliminate,” said Dr. John Morris, Chair of the Coalition for Reliable Medical Access.

Premera Blue Cross, on the other hand, has vigorously advocated for the elimination of the 80th Percentile Rule. It asserts that the original intent of this regulation was to shield patients from balance billing (when a provider bills you for the difference between the provider’s charge and the allowed amount), but it has actually contributed to Alaska’s escalating healthcare costs. According to Premera Blue Cross, the rule allows providers to gradually raise charges with limited motivation to control expenses or join insurance networks.

The Division of Insurance has determined that the 80th Percentile Rule is a driving factor behind the rising medical costs in Alaska.

Medical professionals and providers argue that without adequate reimbursement, many doctors may opt to leave the state.

The coalition of healthcare entities filing suit contends that repealing the rule without implementing a suitable replacement would expose doctors and providers to unfair treatment by profit-driven insurance companies. The absence of this rule could grant insurance companies the power to dictate the winners and losers within the healthcare system, potentially leading to smaller provider networks and reduced access to medical care for certain individuals.

“Repealing the 80th Percentile Rule without a replacement turns back the clock on the significant progress Alaska has made in expanding our healthcare system over the last 20 years and hands complete control over to out-of-state insurance companies,” said Dr. Steven Compton, President of the Alaska State Medical Association. “This ill-conceived regulatory change only magnifies the control big, lower-48 insurance companies continue to hold over patients and their ability to choose the medical provider of their choice. Sadly, in their effort to quietly push this repeal forward, the Division of Insurance and their insurance industry allies continue to misinform Alaskans, misstate facts, and ignore the harm they’re doing to Alaska patients.”

The 80th Percentile Rule protects patients from balance billing and out-of-pocket costs for healthcare, and encourages insurers to work with providers in good faith, the Alaska doctors said. Further, according to the coalition, the federal No Surprises Act applies only to emergent care and does not replace patient protections in the 80th Percentile Rule.

The 80th Percentile Rule does not apply to Alaska Native and American Indian healthcare, which is covered by the federal government, nor to Veterans Administration patients. However, it does affect those covered by major insurers such as Premera Blue Cross and Moda, some of the the largest insurers in the state and in America

The lawsuit was filed in Anchorage Superior Court by the Coalition for Reliable Medical Access, made up of various organizations, including the Alaska State Medical Association, the Alaska Medical Group Management Association, the Alaska Podiatric Medical Association, the Alaska Physical Therapy Association, and the Alaska Chiropractic Society.



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