Regulators must follow Congress to promote fairness in resolving disputes on surprise settlements


For years there was a risk of unexpected medical bills for the patients, tormenting them with the possibility that an unexpected crisis could suddenly plunge them into financial ruin. There has long been a consensus that patients should be protected from the financial burden of unexpected bills. How doctors and insurers should resolve payment disputes was much less clear.

Congress seemed to end this lengthy debate after two years of intense negotiations when it passed the bipartisan No Surprises Act in December 2020. The legislature had examined a large number of policy proposals and carefully weighed the costs and benefits of each one. To ensure fairness to both doctors and insurers, the law clearly states that the median billing rates within the network, which are overwhelmingly supported by the insurance industry, are just one of many factors arbitrators consider when resolving a billing dispute should.

Unfortunately, the federal regulators now want Go back to that bipartisan agreementto give insurance companies another option increase their profits while reducing access to patient care. If adopted, these changes will allow the insurance industry to further reduce their physician networks and injure patients who need frontline physicians in an emergency.

The No Surprises Act was a compromise that was forged after much deliberation and negotiation. The deal struck last year should respect the interests of patients, doctors and insurers. It requires physicians-insurance company payment disputes to be resolved by an independent, external arbitrator, and states that a variety of factors, including but not limited to network median rates, should be considered. These additional factors include, but are not limited to, previously agreed medical service tariffs, the provider’s training and experience, the patient’s visual acuity, the case mix, and the facility’s teaching status. Congress decided that only by taking into account this multitude of factors can arbitrators resolve payment disputes fairly.

The preliminary final ruling by three federal agencies defies the intent of Congress. Instead, the rule allows independent dispute resolution bodies to deviate from the median in the network only in cases where “credible information about additional circumstances” is available [that] clearly shows that the [median in-network] The tariff differs significantly from the appropriate tariff outside of the network. ”This standard is a major factor in favor of the median in the network – and the insurance industry that has advocated it. In a remarkable demonstration of non-partisanship, the chairman and senior member of the House Ways & Means committee recently urged regulators to make the rule consistent with the intent of Congress.

If allowed to enter into force, the rule would have devastating consequences for doctors and patients. Instead of promoting fairness, it would create an artificial cap on how disputes can be resolved. It would not take into account the real cost of medical services and would encourage insurers to avoid contracts with doctors. Applying the rule of extremely low in-network tariffs would lower the median in-network tariffs even further. This race to the bottom is simply not to be won for general practitioners and the patients they care for. It would accelerate the consolidation of the healthcare system, increase costs and jeopardize patient access to emergency and on-call doctors. This scenario is neither hypothetical nor alarming. It is already play in California, where medical care markets are facing major challenges as the state relies on an arbitrary, government-mandated benchmark to resolve surprise billing disputes.

The passage of the No Surprises Act was not easy and was a long time coming. It represents a huge bipartisan investment of time and resources to find the fairest and most effective solution for all parties. Patients literally cannot afford to relive the battles of the past two years. The regulators in the health and social care, labor and finance departments must do their duty by ensuring that the final rule better conforms to the No Surprises Act, as Congress intended. Failure to do so would be an insult to the political decision-making process of our nation and the citizens it is intended to serve.

Dustin Corcoran is President of the Physicians Advocacy Institute and Chief Executive Officer of the California Medical Association.


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