Provider groups sue as surprise billing enforcement nears

The American Medical Association, American Hospital Association and other provider groups are suing the Department of Health and Human Services over a small but important detail of how it is implementing surprise billing legislation. They argue that the arbitration process for unresolved disputes currently favors insurers.

Legislation to protect patients against “surprise bills” is set to go into effect in January. However, provider groups are filing lawsuits against the Department of Health and Human Services, saying the way the agency is implementing the law would give insurers an unfair advantage in negotiations.

The American Hospital Association and the American Medical Association提出投诉on Dec. 9, joined by UMass Memorial Health Care, Renown Health, and two physicians in North Carolina. HHS, the Labor Department, the Treasury Department, and the Office of Personnel Management were listed as defendants. Earlier in November, the Association of Air Medical Services (AAMS) also提起诉讼。

The lawsuits focus on a narrow provision that determines how disputes between insurers and providers are resolved, which providers argue “places a heavy thumb on the scale” of the resolution process.

When an insurer and a provider can’t reach an agreement on how much an out-of-network service should cost, they can work with an arbiter to reach an agreement. Where the AHA and the AMA raise issue, is that arbiters are directed to base those negotiations on a qualifying payment amount, usually insurers’ median in-network rate for that service.


例如,在紧急情况下,患者可能被传送到空置的设施。即使是计划内的网络手术,如果其中一个提供护理,如麻醉师,如无网络的人,患者仍然可以陷入账单。法律也适用于空气救护车,这可以运行十of thousands of dollars, and are often not covered.

For people covered by large employer plans, roughly one in five emergency visits result in a surprise bill, according toan analysis by The Peterson Center on Healthcare and the Kaiser Family Foundation.The Congressional Budget Office estimated the legislation would reduce premiums by about 1%, by fixing out-of-network rates to the median paid by insurers.

根据新法律,保险公司将被要求覆盖无网络索赔并适用于网络成本共享。它还将禁止医院和医生将账单患者超过保险公司决定的网络金额,否则他们可能会面临每次违规的罚款高达10,000美元的罚款,according to an analysis通过Kaiser家族基金会。

Providers would first submit an out-of-network bill to a health plan. That plan must respond within 30 days with the in-network cost sharing amount for that service. Only then can providers bill patients.

If they can’t reach an agreement, they can go through an independent dispute resolution process. However, arbiters are instructed to base those negotiations on insurers’ median in-network rates, which is where detractors say HHS’ implementation of the rule differs from Congress.

The lawsuit won’t necessarily stop implementation of the rule. According to the complaint, the AMA and AHA are seeking to remove provisions specifying that arbitrators must pick the offer closest to the qualifying payment amount.

Photo credit: zimmytws, Getty Images


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