Lawmakers Seek Changes to No Surprises Act Implementation

A bipartisan group of 152 House members wrote to the secretaries of Health and Human Services, Treasury and Labor and urged them to amend the interim final rule (IFR) that will implement the No Surprises Act.

The interim final rule is an arbitration process that explains how providers and payers will determine out-of-network rates when surprise billing occurs. The rule allows individuals with employer-sponsored or individual health plan the ability to dispute denied payment for certain claims.

If the parties are unable to come to an agreement, either party may start independent dispute resolution process (IDR).  Both parties will jointly select a certified IDR entity that will mediate the process and select a binding determination.

Additionally, the conflicting parties will submit their proposed rates for the out-of-network services and the IDR entity will issue a determination based on the payer’s median contracted rate for the same or similar service in an area.

“We urge you to revise the IFR to align with the law as written by specifying that the certified IDR entity should not default to the median in-network rate and should instead consider all of the factors outlined in the statute without disproportionately weighting one factor,” the representatives stated in the letter.

The representatives believe the IDR entity should be more balanced by also considering other factor such as provider training and quality of outcomes, market share of parties, patient acuity or complexity of services, teaching status, demonstrations of previous good faith efforts to negotiate in-network rates, and prior contract history between the two parties.

“Unfortunately, the parameters of the [independent dispute resolution] process in the IFR released on September 30 do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes,” the representatives wrote.

Providers are sharing similar concerns regarding the IDR process. Recently, the Texas Medical Association (TMA) has brought a lawsuit against various federal agencies arguing that the interim final rule process is unfair and “undermines Congress’s design.

“Nowhere did Congress specify that the QPA, or any other factor for that matter, should be given primacy over the other enumerated factors,” TMA wrote in the lawsuit. “At the same time, they will undermine providers’ ability to obtain adequate reimbursement for their services, to the detriment of both providers and the patients they serve.”