Providers insist on unexpected changes to the billing process

Healthcare providers continued to push officials to change the way they resolve network billing disputes and asked several federal agencies to clarify the requirement to provide uninsured patients with cost estimates for treatment.

An interim final rule establishes a dispute resolution element in the No Surprises Act, and the policy comment period ended on Monday. The rule states that arbitrators assisting payers and out-of-network providers in billing disputes should first consider the plan’s median on-net rate for a service provided in a region when the parties cannot resolve the payment dispute. While insurers argue that policy levels the game, suppliers argue that it tilts the balance in insurers’ favor.

“What should have been an independent review for both sides is now gone. In short, departments have removed this important constraint on plans and issuers, creating an almost insurmountable set of conditions for providers, ”wrote the American Hospital Association. v letter

The No Surprises Act states that arbitrators must consider a list of factors when deciding how much a payer should reimburse an out-of-network service provider. The list includes the median on-net payment rate, known as the qualified payment amount. It can also take into account the market share of each party, the supplier’s quality indicators, the patient’s visual acuity and a number of other factors.

Congress was victorious when it decided that billing disputes should be resolved through arbitration. But providers have been unhappy with the rules since their release in September. The Texas Medical Association is suing the federal government in an effort to block the ruling, and a hearing is scheduled for February 4.

The AHA wants officials to establish a final rule requiring arbitrators to consider all of the factors on the list.

Providers argue that the federal government’s decision to calculate the average on-net payment rate, as the implied external rate makes other factors less important and contrary to legislators’ wishes. The Federation of American Hospitals wrote in its letter that he does not believe that the federal government had the power to determine how payments were evaluated by arbitration bids.

“Congress wanted a fair and balanced system for resolving disputes that did not favor any factor … This could discourage insurers from offering fair contracts with doctors and limit patients’ access to health care,” wrote the American Academy of Neurology in their comments.

Lawmakers themselves disagree on whether the rule is in line with their vision. Bipartisan group 152 deputies sent a letter to heads of federal departments in November urging them to change the rule so that median on-net payment rates would not be defaulted, and leaders of the influential House Methods and Means Committee sent a similar message in October. But the leadership of the Home Education and Labor Committee continues to support rule.

“In addition to the simple language of the bylaws, the approach adopted by the IFR is in line with Congress’s bipartisan goal of lowering premiums and preventing inflation in health care costs,” said committee chairman Bobby Scott’s November 19 letter. .) and a senior member of Virginia Fox (RN.C.).

Insurers say it makes sense to place more emphasis on intra-network median rates in disputes. Ensuring that off-chain rates are similar to those that lead to predictability in the dispute resolution process, which can help move towards no need for the process at all, writes AHIP in its letter… The insurance lobby also said the move could encourage more suppliers to go online.

“Without an objective standard to guide (arbitrators), the question of how off-network providers should be compensated becomes a highly subjective decision when arbitrators brought in through (arbitrators) have to guess and the predictability of IDR becomes random,” AHIP wrote.

The AHIP also asked officials to issue guidance on how to determine if state law applies to a claim and how the web portal functions when it is unclear whether a dispute should be resolved through federal or state processes.

In addition, some provider groups are concerned about the rule requirement that providers offer uninsured or self-paying patients with an estimate of the cost of treatment, which confuses patients. Other services may be scheduled separately and these costs will not be included in the assessment given to the patient. American Association of Medical Groups wrote a letter in the commentary.

The AHA has called on the Department of Health and Human Services to align its hospital price transparency requirements with its cost estimation policy. Hospitals that meet the patient scoring tool requirements for price transparency should also be considered eligible to estimate the cost of unexpected billing, the AHA wrote in its letter.

Unexpected billing rules take effect on January 1st.

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