Surprise billing regulations amaze vendors, reject congressional intent

The Centers for Medicare & Medicaid Services (CMS) and several agencies released an “Interim Final Rule” on September 30, 2021, which outlines the process by which off-grid reimbursement disputes between providers and payers will be resolved under the federal law. The proposed surprise billing regulations have been met with contempt by the supplier community, as key provisions contradict the carefully crafted compromise approved by Congress in the final weeks of 2020.

Throughout 2020, several US House and Senate committees held separate hearings on surprise billing as the public increasingly demanded relief from unexpected medical bills for services provided at facilities in the United States. network. The leaders of these committees largely had their own conception of how to solve the problem and in December, despite public pressure, it appeared that no legislation would be passed until Congress adjourned and took office. ‘a new president.

Disagreement within political parties and among the 4 congressional committees centered largely on the type of guidelines that would be used to determine reimbursement for non-urgent services provided by off-grid providers at grid facilities. The first proposals that set a benchmark rate based on median local network charges were ultimately rejected because lawmakers understood that network charges do not reflect actual payment rates. Ultimately, the bipartite agreement established a process in which external arbitrators would decide payment rates through arbitration. Network charges would not be ignored, however, as the law required arbitrators to take into account the network’s median rate, among several other pieces of information submitted by the parties, in making their decision.

The delicate balance that had been struck in the No Surprises Act was awkwardly upset by regulations released by the Biden administration on September 30. Instead of viewing the networked median rate as a single piece of information to consider in the arbitration process, the proposed rule directs the arbitrator to consider the amount used by insurers for patient cost sharing purposes – identified as the “qualifying payment amount” – as the primary factor in determining the total payment to off-grid providers. In doing so, the important arbitration process would be conducted in such a way as to tip the balance in favor of health insurers.

The thunderous opposition from doctors and healthcare systems noted that the rule would have dire and far-reaching implications. In a press release, the Texas Medical Association (TMA) said that “administration’s short-sighted approach will make it harder for patients to access care by lowering reimbursement rates and encouraging companies to ‘assurance of continuing to strengthen their networks. It will be difficult for small groups of doctors to continue to care for patients. 1 In another press release, the American Medical Association (AMA) called the interim final rule “an undeserved giveaway to the insurance industry that will narrow health care options for patients.” “2

In the statement, WADA President Gerald A. Harmon, MD, said the regulations “ignore the role of the insurance industry in creating the problem of surprise billing at the expense of independent medical practices. whose ability to negotiate supplier network contracts continues to erode “.2

“Congress appreciated the negative consequences of domestic pricing for health services and devoted considerable time and effort to developing a strong independent dispute resolution process to maintain market balance and preserve access to care, which the administration has apparently ignored, ”added Harmon.2

Beyond press releases and harsh statements, steps are being taken on several fronts to change the proposed regulations.

The AACU has joined in the effort calling on the administration to remove the directive that arbitrators anchor their determination to the amount of the eligible payment, and instead let them consider all eligible information submitted by the parties to substantiate their offer. The draft joint letter insists that the signatories are not asking to delay or cancel any of the patient protections in the No Surprises Act. He is simply asking that the rule be corrected to align with the intention of Congress.

The federal government has also been sued by the TMA for its interpretation of the law. The TMA lawsuit seeks to remove the section of the settlement that ties arbitrators’ decisions to the amount of allowable payment from insurance companies because that figure “distorts a crucial benchmark for the dispute resolution process,” according to one. article from The Texan.3

In a statement, TMA President Linda Villareal, MD, concluded: “We are disappointed that the Biden administration has ignored the intention of Congress and essentially set up the arbitration system to operate as a casino, with health insurers playing the role of the house. Everyone knows the house always wins. With the current rule, patients, doctors and our country lose out. “1

The references

1. TMA is suing the federal government for an unfair rule regarding the surprise billing law. Press release. Texas Medical Association. October 29, 2021. Accessed November 15, 2021.

2. The regulation of surprise billing is a surprise gift for the insurance industry. Press release. American Medical Association. October 2021. Accessed November 15, 2021.

3. The Johnson B. Texas Medical Association is suing the federal government over the surprise billing rule. texan. October 29, 2021. Accessed November 15, 2021.

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