Industry groups urge agencies to revamp surprise billing rule

The No Surprises Act’s independent dispute resolution (DR) process unfairly favors payers and should be overhauled, according to the American Hospital Association (AHA). The AHA outlined its concerns in comments submitted on an interim final rule (IFR), Requirements Related to Surprise Billing; Part II, released in September. The IFR, along with a previous rule released in July, implement the requirements of the No Surprises Act.

The AHA expressed its agreement with the goals of the act, stating that, “No patient should be fearful of receiving a bill for out-of-network care that they received during an emergency or when they reasonably could not have known the network status of the provider.” However, the act’s implementation is flawed, according the AHA.

The AHA’s main concern is how the IDR process has been distorted to favor the plans and issuers, negatively impacting patients and providers as a result. The AHA urged the agencies to “restore the independence of the IDR entities” to avoid abuses of the act.

The American Society of Anesthesiologists (ASA) sounded the alarm about potential misuse of the act by payers. According to information obtained by the ASA, BlueCross BlueShield of North Carolina threatened to terminate contracts with physician practices if they did not accept payment reductions of 10%–30%.

In hopes of preventing similar occurrences in the future, the AHA and the American Medical Association filed a lawsuit against the federal government. “Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended,” said Rick Pollack, president and CEO of the AHA.

The AHA isn’t the only industry stakeholder to express its concerns about the No Surprises Act. The Workgroup for Electronic Data Interchange (WEDI) discussed the act’s lack of standards and automated processes related to the transfer of data in its comments on the IFR. To avoid frivolous arbitration, WEDI also advised HHS to use a percentage of billed services as the threshold for arbitration rather than the $400 threshold outlined in the IFR.

WEDI noted that due to the inherently complex and unpredictable nature of many medical services, exact estimates may be difficult to provide. Using a percentage rather than a fixed dollar amount would accomplish the same goal, avoid unnecessary arbitration, and simplify processes for patients and providers.

Revenue integrity professionals should ensure internal policies and processes are updated to comply with the IFRs and update staff training materials and resources. Review CMS’ fact sheets on each IFR as well as technical resources and other guidance. Monitor communications from payers and work closely with payer contracting staff to address any concerns.

Editor’s note: Find more NAHRI resources on the No Surprises Act here, and access more on price transparency here.