Are You Prepared for the Surprise Billing Ban?

A new law designed to limit surprise medical bills resulting from out-of-network care that goes into effect Jan. 1, 2022, is facing legal challenges from two organizations.

In late October, the Texas Medical Association filed a lawsuit against the U.S. Department of Health and Human Services alleging that the interim final rule on surprise billing goes against the intent of Congress about how to implement the dispute resolution process meant to determine fair payments for out-of-network care.

The Association of Air Medical Services (AAMS) followed by filing a lawsuit in November.

Even some members of Congress have come out against it. In a letter to HHS, 152 lawmakers stated that the way the rule was written “does not reflect a policy that could have passed Congress and does not create a balanced process to settle payment disputes.â€

The trade groups question how the qualifying payment amount (QPA), which is determined by a plan’s median in-network contracted rate for a particular geographic area, is used to arrive at rates for out-of-network providers.

“”The QPA is to be the overriding factor in this decision-making process,” AAMS said in a news 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.”

TMA, for its part, said it believes that the rule incentivizes health plans to shrink their networks and cut physician payments, while at the same time makes it more difficult for physicians to receive a fair payment. Physicians “will often receive lower reimbursement that does not reflect the fair market value of their services, and some patients will lose access to their in-network physicians.â€

The so-called No Surprises Act was passed by Congress as part of the 2020 year-end omnibus spending bill. Surprise medical billing generally happens when a patient receives an unexpected bill from a provider and didn’t understand the provider was not in their insurer’s network. This generally results in what’s known as balance billing, a practice providers use to charge a patient the balance of bill not paid by insurance. In many instances, there have been horror stories where patients are left to pay tens of thousands of dollars in medical bills.

The AAMS has a huge stake in the fight in that often patients involved in life-or-death situations may need to be transported via a helicopter. In cases where this occurs, patients are taken to the nearest or most appropriate facility which may, or may not, be in their insurer’s network.

“By building this process in favor of the payor, our healthcare systems will suffer through reduced payments for necessary services, deepening an ongoing public healthcare crisis,†AAMS stated in a news release.

How all of this will shake is yet to be known since some the details of the legislation still must be worked out and litigation is pending.

However, those impacted by the No Surprises Act should be prepared to comply with the Act’s requirements. Once final, The Health Law Offices of Anthony C. Vitale can assist providers in navigating the complexities of complying with the new rule and associated reimbursement issues. You can contact us at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.