Payers and providers must start complying with the federal ban on surprise billing by Jan. 1, and the fight over rules implementing the ban is heating up as provider groups object to what they think is a favoring of insurers despite consumer groups supporting the current proposed arbitration process.
Last year, Congress passed the No Surprises Act in an effort to shield patients from surprise medical bills — a persistent issue for American consumers receiving care from hospitals or doctors outside of their insurance networks.
A key sticking point is the arbitration process, and how the qualifying payment amount (QPA) — determined by a plan's median in-network contracted rate for a geographic area — is used to arrive at rates for out-of-network providers.
The Association of Air Medical Services filed a lawsuit in federal court challenging the rules Tuesday, claiming reliance on a QPA strays from Congress' intent when passing the law that "no single statutory factor receives special weight" in the arbitration process.
"The QPA is to be the overriding factor in this decision-making process," AAMS said in a release. "This means that insurers will be able to know exactly how the [independent dispute resolution] entities will resolve these disputes, making the IDR and the open negotiation that precedes it a foregone conclusion."
Surprise bills for air ambulance trips can be notoriously expensive, as the market is characterized by limited in-network contracting, with patients at risk of surprise bills averaging $20,000 for such trips, according to new research from the Brookings Institution and the University of Southern California.
Other groups have sued for the same reason, including the Texas Medical Association, which filed a lawsuit against HHS, the Labor Department, the Treasury Department and the Office of Personnel Management claiming the dispute resolution process will be skewed toward payers because the final rules give too much weight to the QPA.
Congress is also spatting over the rules, with 152 lawmakers penning a letter Nov. 5 stating the latest rules "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."
Assuming the median-in network rate for appropriate payments without considering other factors would establish a de-facto benchmark rate for the arbitration process, the lawmakers wrote.
"This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law," the letter said.
The process could also impact reimbursement for in-network services, potentially exacerbating existing health disparities in rural and underserved communities, the lawmakers wrote.
But other groups still support the ban and say its rules will effectively protect consumers for both surprise medical bills and skyrocketing healthcare costs.
The rules guiding the arbitration process are a form of consumer protection, 63 organizations representing patients, consumers, unions and employers said in a Tuesday letter.
An over reliance on out-of-network charges, particularly among Wall Street-backed providers, extracts maximum costs from patients, employers and health systems, thus driving up premiums and contributing to ever-rising healthcare spending in America, they said.
"As outlined in the interim final rule, it is only by reinforcing the QPA as the overriding and primary factor for determining final payment that the No Surprises Act can achieve the $17 billion in cost savings outlined by the Congressional Budget Office," the groups wrote.