AHA Calls For More Payer Oversight In No Surprises Dispute Resolution

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Dive Brief:

• The American Hospital Association called for more oversight into payers in comments submitted on a proposed rule that would overhaul the embattled surprise billing dispute resolution process.
• In comments published earlier this week, the AHA argued the proposed rule still needs to address how insurers calculate the qualifying payment amount — the median contracted rate for a service — and make that information available to providers and independent dispute resolution entities. 
• Regulators also haven’t explained how they’ll handle oversight for some problems, like when a health plan doesn’t pay up after an IDR determination, the AHA wrote. Providers have previously accused insurers of ignoring surprise billing decisions or failing to pay them in full.

Dive Insight: 

The No Surprises Act, which went into effect in 2022, aims to protect patients from unexpected bills after inadvertently receiving care from out-of-network providers.

The law set up a process to resolve payment disputes, where providers and insurers enter into baseball-style arbitration and a third-party arbiter picks one payment offer, submitted by either side, as the final amount. 

But the rollout has been rocky. Providers have filed lawsuits arguing the process favors insurers, and the IDR has been halted multiple times. 

Insurers say the process has already prevented millions of surprise bills, which could have devastating financial consequences for patients. But many more claims are going through the dispute resolution process than anticipated, and payers argue that providers are exploiting the system.

In the fall, regulators proposed a rule that aimed to make the dispute resolution process more efficient and streamline communication between the parties, hopefully cutting the number of claims submitted.

The AHA said the proposals address many hospital and health system concerns, including allowing them to batch items and services associated with a single patient, requiring payers to share additional information and creating a process for the government to assist with backlogs. 

But the lobbying group also argued batched claims shouldn’t be limited to 25 line items, patients with self-insured coverage should be batched at the employer level instead of through the administrator and that administrative fees are still cost-prohibitive. 

Payer oversight still isn’t sufficient either, and the AHA urged regulators to address those issues through additional rulemaking.

“These delays in oversight have contributed to a fundamentally imbalanced situation where payers are able to inappropriately withhold providers’ revenue — the revenue they need to finance patient care — knowing that the likelihood of being caught or challenged is low,” Stacey Hughes, the AHA’s executive vice president of government relations and public policy wrote in the comments.