Providers promote changes to the accidental billing resolution process


Health providers continue to push officials to change the way they handle out-of-network billing disputes and require several federal agencies to explicitly request estimates of the cost of care for uninsured patients.

The interim final rule establishes the dispute resolution elements of the No Accident Law, and the comment period for the policy ends on Monday. The rule stipulates that when the two parties are unable to resolve the payment disagreement, the arbitrator assisting the payer and the out-of-network provider in a billing dispute should first consider the median in-network rate of the service planned to be provided in the region. Although the insurance company said the policy is fair competition, the supplier believes that it has tilted the scale of the insurance company.

“What should have been independent inspections of both parties no longer exists. In short, these departments have abandoned this important restriction on plans and issuers, while creating an almost insurmountable set for providers. Conditions,” the American Hospital Association wrote in a letter.

The No Accident Law stipulates that arbitrators should consider a series of factors when deciding how much service the payer should reimburse to the out-of-network provider. The list includes the median payment rate within the network, called the eligible payment amount. It can also consider the market share of each party, the quality measurement of the provider, the acuity of the patient, and several other factors.

Congress submitted Vendor wins When it decides that billing disputes should be handled through arbitration.But the supplier has depressed Regarding the regulations since its release in September.this Texas Medical Association The federal government is sued for trying to block these regulations, and a hearing is scheduled for February 4.

The AHA hopes that officials will develop a final rule that requires arbitrators to consider all the factors on the list.

The provider argued that federal officials decided to calculate the median in-network payment rate because the assumed out-of-network payment rate made other factors less important and went against the wishes of lawmakers.The American Hospital Association in its letter It believes that the federal government does not have the authority to establish procedures for how arbitrators should evaluate payment proposals.

The American Academy of Neurology wrote in its comments: “Congress wants a fair and balanced system to resolve disputes. No single factor takes precedence over other factors… This may inhibit insurance companies from providing fair contracts to doctors. And reduce the patient’s chances of getting care.”

The legislators themselves did not agree on whether the rule fits their vision.A bipartisan group 152 members In November, I wrote to the head of the federal department urging them to change the rules. Therefore, the median payment rate in the network is not the default value. The leader of the influential House Ways and Means Committee issued a similar message in October.But the leadership of the House Education and Labor Committee keep supporting rule.

Committee Chairman Bobby Scott (D-Va.) and ranking member Virginia Fox (RN.C.) said.

Insurance companies say it makes sense to give more weight to the median in-network rate in disputes. AHIP wrote in its report that ensuring that the out-of-network rate looks similar to the predictability that led to the dispute resolution process, which helps to eliminate the need for the process from the start. letterThe insurance lobby also stated that this move may encourage more suppliers to move into the network.

“If there is no objective standard as the guidance of (arbitrators), the question of how to compensate providers outside the network becomes a highly subjective decision. Arbitrators who have signed contracts with (arbitrators) must guess, and the predictability of IDR becomes fragmented. , “AHIP wrote.

AHIP also requires officials to issue guidelines on how to determine whether state laws apply to claims and how the portal operates when it is unclear whether the dispute must be handled through federal or state procedures.

In addition, some provider groups are concerned that the rule requires providers to provide uninsured or self-paying patients with estimates of the cost of care, which can confuse patients. Other services may be arranged separately, and these costs will not be included in the estimates for patients. American Medical Group Association Wrote in the comment letter.

AHA encourages the Ministry of Health and Human Services to coordinate Hospital price transparency Cost estimation policy requirements. The AHA wrote in the letter that hospitals that meet the requirements of the price-transparency patient estimation tool should also be deemed to meet the requirements for unexpected billing cost estimation.

The accidental billing regulations will take effect on January 1.



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