Infectious Disease

The No Surprises Act faces multiple lawsuits against the determination of billing disputes

January 05, 2022

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The No Surprises Act, which officially went into effect January 1 to protect patients from unexpected medical bills, has already faced several lawsuits from health organizations.

The bill was passed by Congress in 2020 as part of the coronavirus relief package. It is designed to protect patients from unexpected care costs outside the network.

According to a Health Claims Analysis by the Peterson Kaiser Family Foundation, about one in five emergency filings and one in six hospital stays on the network in 2017 resulted in at least one off-network fee, some of which are in the hundreds to thousands of dollars.

Under the No Surprises Act, patients are only responsible for the costs they would have paid for their on-grid care bill or, for uninsured patients, for what they called a “good faith estimate” prior to treatment, according to a Government press release. Any remaining amount must be paid directly between the insurer and the provider.

Litigation ongoing

However, the American Hospital Association, AMA, Renown Health, UMass Memorial Health Care Inc., and two North Carolina-based physicians have jointly filed lawsuits against HHS, the Office of Personnel Management, and the Departments of Labor and Treasury under a federal regulation that created, to implement the new law.

In a separate complaint, the American Society of Anesthesiologists, the American College of Emergency Physicians, and the American College of Radiology have also filed lawsuits against these departments. In addition, the American Academy of Orthopedic Surgeons has issued a formal letter to HHS and the labor and finance departments.

In a statement issued on behalf of its organization and the American Hospital Association, the AMA announced that it is contesting a specific federal rule that “ignores the requirements of the No Surprises Act and would result in restricted access to patient care.” These organizations, which helped in the effort to get the No Surprises Act passed, said they support the law but not how it will be implemented.

The provision under speculation created by federal regulators after the bill was passed provides for an independent dispute settlement procedure that assumes that the median tariff set by insurers in the network is the appropriate outside network tariff that doctors and hospitals can charge . The American Hospital Association and AMA argued that this provision did not take into account the education or quality of care provided.

“The skewed process will ultimately limit access to care by preventing meaningful contract negotiations, reducing provider networks, and promoting unsustainable compensation for teaching hospitals, doctor’s offices and other providers that greatly benefit patients and communities,” the press release said.

The qualified payment amount set by insurers “sets an artificially low benchmark payment for all treatments – whether online or not that may not support wider access to care – especially in underserved areas,” the American College of Emergency Physicians said in a press Release.

AMA President Gerald E. Harmon, MD, Healio said that maintaining care for providers is unsustainable and can lead to closer networks for insured and uninsured patients, especially in rural and underserved areas.

“I think we are at risk of losing more doctors and more independent practices and smaller rural hospitals are at risk of closing their doors,” he said.

The current dispute settlement process allows insurance companies to set the standard lower than the cost of providing the care, Harmon said.

“It just confuses me. I can’t imagine what they thought when they interpreted the regulation that way, ”he added.

Legislative support

On November 5, 2021, 152 congressmen sent a letter calling for the provision to be revised.

“[The provision] violates the law and could incentivize insurance companies to set artificially low payment rates, which would constrict provider networks and compromise patient access to care – the exact opposite of what the law intended, “the lawmakers wrote. “It could also have far-reaching implications for reimbursement for in-network services, exacerbating existing health inequalities and patient access problems in underserved communities in rural and urban areas.”

The American Academy of Orthopedic Surgeons also criticized the determination of the good faith estimate and requested clarity on the provider-patient dispute settlement process for uninsured patients in circumstances where the total medical bill owed exceeds the good faith estimate originally submitted.

A revision of the federal rule of the bill has not yet been issued. When asked for comment, HHS and CMS spokesman Healio referred to the government press release. The bill will “work to encourage competition in health care and other areas of the American economy,” said the press release, which made no mention of the ongoing proceedings.

“The No Surprises Act is the most critical consumer protection act since the Affordable Care Act” Xavier Becerra, JD, HHS secretary said in the press release. “After years of bipartisan efforts, we are finally providing hard-working Americans with the federal guard rails they need to protect them from surprise medical bills. We get patients out of the middle of the food battle between insurers and service providers and ensure that they are not confronted with eye-catching, bankrupt medical bills. “

Laura Wooster

Changes to the law during the implementation process “but undermine the overarching goal of patient protection”, Laura Wooster, Senior vice president of advocacy at the American College of Emergency Physicians, said Healio.

“Unless changed, this law will further strengthen health plans to cut or terminate existing contracts and push even more emergency doctors off the network, making it harder for patients to get access to emergency care,” she said, adding that doctors already doing this burnout because of work and increasing financial stress.

If the dispute settlement mechanism provision is left unchanged, “it will have a negative impact on the availability and access to medical care in all areas,” Harmon said.

References:

AAOS on Consequences and Mismatches of Regulations with the No Surprises Act. https://www.aaos.org/aaos-home/newsroom/press-releases/aaos-on-consequences-and-misalignment–of-regulations-with-the-no-surprises-act/. Published December 7, 2021. Retrieved January 4, 2022.

AMA and AHA are filing a lawsuit over the final settlement of the No Surprises Act. https://www.ama-assn.org/press-center/press-releases/ama-and-aha-file-lawsuit-over-no-surprises-act-final-rule. Published December 9, 2021. Retrieved January 3, 2022.

The American College of Emergency Physicians, the American College of Radiology, and the American Society of Anesthesiologists are filing lawsuits against the federal government’s No Surprises Act. https://www.emergencyphysicians.org/press-releases/2021/12-22-21-american-college-of-emergency-physicians-american-college-of-radiology-and-american-society-of-anesthesiologists- Filing-a-lawsuit-against-the-federal-governments-implementing-rules-for-no-surprise-law. Published December 22, 2021. Retrieved January 3, 2022.

That means the new ban on surprising medical billing for you. https://www.npr.org/sections/health-shots/2021/10/14/1045828215/ban-on-surprise-medical-bills. Published December 30, 2021. Retrieved January 3, 2022.

HHS starts the new year with new protection against unexpected medical bills. https://www.cms.gov/newsroom/press-releases/hhs-kicks-new-year-new-protections-surprise-medical-bills. Published January 3, 2022. Accessed January 3, 2022.

Patients celebrate important safeguards against unexpected bills. https://newsroom.heart.org/news/patients-celebrate-important-protections-against-surprise-billing. Published January 3, 2022. Accessed January 2, 2022.

Wenstrup, Suozzi lead 150 members to demand that the administration properly implement the surprise billing laws. https://wenstrup.house.gov/updates/documentsingle.aspx?DocumentID=405203. Published November 5, 2021. Retrieved January 3, 2022.

An examination of surprising medical bills and suggestions to protect consumers from them. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/. Published February 10, 2020. Retrieved January 4, 2022.

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