Medicine & Health

Providers and insurers want more details, leniency on surprise billing ban

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Providers and insurers want the federal government to take it easy on them as they try to put the surprise billing ban into practice, according to comments on the first regulation stemming from the No Surprises Act.

Both industries say they want to protect consumers against balance billing but remain worried they don’t have essential details about how the ban will work in the real world nor enough time to carry out needed changes. They’re especially concerned about the non-consumer-facing aspects of the ban, including the finer points of setting qualifying payment amounts and how arbitrators will use that in the independent dispute resolution process.

Making the qualifying payment amounts workable will take more than three months alone, the health insurance lobbying group AHIP wrote in a letter.

“There are too many outstanding implementation questions that require answers in short order: What constitutes a contracted rate? From where to pull contracted [rates] within a geographic region? How is the proper median identified? How should the cost-sharing for enrollees be calculated and communicated? What paperwork is necessary to facilitate accurate communications with contracted providers, facilities, employers and enrollees?” AHIP wrote.

Insurers asked the federal government to give them until January 2023 to determine how they calculate qualifying payment amounts, given the current uncertainty around the rules and competing priorities like compliance with the Transparency in Coverage rule.

“Under the safe harbor, plans and issuers should be permitted to adjust cost-sharing in favor of the enrollee as these processes are implemented, and the [qualifying payment amount] methodology is refined,” AHIP wrote.

Hospitals also want regulators to cut them a break while they educate their staff, design new workflows and figure out how to share information with health plans.

“A substantial portion of the regulations have yet to be released, and many of the policies will require new information flows across different entities for which no standard transactions currently exist. Reliance on manual information sharing and proprietary communication flows (such as unique plan portals) will not be workable for the scale of new information that will need to be shared,” the American Hospital Association wrote in a letter.

Providers and insurers are asking regulators to establish a new, multi-stakeholder working group to hash out the details of implementing the surprise billing ban because it cuts across providers, payers, third-party administrators, coding and billing specialists, and others.

“Due to the number, extent and complexity of technical implementation challenges created by the No Surprises Act, we recommend the departments create an operations working group of healthcare stakeholders to discuss the operational challenges and how to address them as quickly as possible,” AHIP wrote.

President Joe Biden’s administration banned surprise billing earlier this year after Congress passed the No Surprises Act in December. But providers and insurers argue they won’t be able to meet their obligations on time because the federal government still hasn’t shared critical information about the new requirements or how it will resolve billing disputes. Regulators will outline how the arbitration process will work in the coming weeks, giving the healthcare industry a short timetable to implement the changes.

Medical groups want more flexibility on the notice and consent provisions of the No Surprises Act, arguing that regulators should focus on whether providers are following the spirit of the law instead of specific requirements.

“The strict and arbitrary timing requirement for the surprise billing notice and consent process will upend physician practice operations. If a patient requires a service be scheduled for that day with an out-of-network clinician, it can require that the physician reschedule numerous other patients and services to accommodate the strict three-hour timeline for services,” the Medical Group Management Association wrote in a letter.

Hospitals also want regulators to ensure they won’t be held responsible if out-of-network providers don’t get proper notice and consent or fail to provide good faith estimates.

“The departments should clarify that the nonparticipating providers in the facility should be responsible for obtaining the notice and consent for the items and services they provide,” the Association of American Medical Colleges wrote in a letter.

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