Some doctors, medical associations and members of Congress are complaining that the rule enacted by the Biden administration this fall to implement legislation that prevents unexpected health bills is actually beneficial. to insurance companies and do not follow the spirit of the law.
Anna Moneymaker / Anna Moneymaker
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Anna Moneymaker / Anna Moneymaker
Some doctors, medical associations and members of Congress are complaining that the rule enacted by the Biden administration this fall to implement legislation that prevents unexpected health bills is actually beneficial. to insurance companies and do not follow the spirit of the law.
Anna Moneymaker / Anna Moneymaker
The man who allowed Congress to pass legislation limiting unexpected health bills has disbanded. A bipartisan group of 152 lawmakers backed the Biden administration’s plan to regulate the law and health providers, warning of dire consequences for underserved patients.
For many years, patients have had to deal with surprise bill when they get treatment from hospitals or doctors outside of their insurance company’s network. This usually happens when a patient seeks care at a network hospital but a doctor such as an emergency room doctor or anesthesiologist who treats the patient is not covered by the insurance plan. The insurance company will only pay a small portion of the bill, and the patient will no doubt be responsible for the remainder.
Parliament passed The Act has no surprises December last year to protect patients from that experience after long, arduous negotiations with providers and insurers finally resulted in an agreement that lawmakers on both sides are deemed fair: a 30-day negotiation period between the medical provider and the insurance company when a billing dispute arises; will then be arbitrated if agreements cannot be reached.
NS rule, which will go into effect in January 2022, freeing patients from the war. Providers and insurers must settle themselves under the new policy.
In releasing the rule, the Centers for Medicare & Medicaid Services pointed out an analysis of the Congressional Budget Office that the No Surprises Act would reduce health insurance premiums by about 1% and cut the federal deficit by $17 billion.
Lower premiums are a particularly important goal for the administration and some of its allies, such as patient advocacy groups and labor unions.
But now many doctors, their medical associations and members of Congress are crying out, arguing the rule enacted by the Biden administration in September for implementing legislation that favors insurers and disobeying the spirit of the law.
A letter of complaint signed by 152 legislators
“The Regulator’s recently proposed regulation to initiate law enforcement does not follow the intent of Congress and may encourage insurers to set artificially low payout rates, which would narrow provider networks and potentially force small facilities to close, thereby limiting patients’ access to care.” Representative Larry Bucshon, R-Ind., is a physician and has been instrumental in spearheading letter complaint this month, told us in a written statement.
Nearly half of the 152 lawmakers who signed that letter were Democrats, and many of the doctors serving in the House signed them. But the backlash did not win the support of some strong-willed Democrats, including Representative Frank Pallone, N.J., chairman of the Energy and Commerce Committee, and Senator Patty Murray. Wash., Chairman of the Senate Health, Energy, Work and Pensions Committee. , who wrote to the authorities urging officials to move forward with their plans.
Several members of Congress who are also doctors held a meeting with the administration late last month to complain, according to aides to the Capitol Hill lawmakers who could not speak on the file because they are not allowed to do so. A staff member familiar with the call said: “Doctors in Congress are very angry about this. “They wrote the law very clearly the way they did after a year, or two, arguing about which way to go.”
The controversy concerns a part of the proposed final rules that focus on arbitration.
Legislators’ letter – organized by Delegates Thomas Suozzi, DN.Y., Brad Wenstrup, R-Ohio, Raul Ruiz, D-Calif. And Bucshon – note that the law specifically forbids arbitrators from favoring a particular standard for determining what a supplier should be paid. Explicitly excluded are Medicare and Medicaid charges (which tend to be lower than insurance company rates) and the average doctor billed rates (which tend to be much higher).
Arbitrators will be instructed to consider the average on-net price for services as one of several factors in determining a reasonable payment. They will also have to consider items such as physician training and outcome quality, local market share of stakeholders where one party may have too much leverage, patient understanding, and complexity. of past history and services, among other things.
But proposed rule did not instruct the arbitrators to consider those factors equally. It requires them to start with a so-called qualified payment amount, which is defined as the average rate the insurance company pays network providers for similar services in the area. area.
If a doctor thinks they deserve a better rate, they are allowed to point to other factors allowed by law – something medical practitioners in Congress believe is against the bill. that they wrote.
The provisions in the new rule “do not reflect how the law is written, do not reflect a policy that may have been passed by Congress, and do not create a balanced process for resolving payment disputes,” the statement said. the legislator told administration officials in the letter.
Opponents of the rule argue that the consequence would be a process that favors insurers over doctors and pushes prices too low. They also argue that it will harm networks, especially in rural and underserved areas, because it creates an incentive for insurers to reduce the rates they pay for services. network providers. If the in-network rate is lower, the default rate in the arbitration is also lower.
That is the argument made specifically in a lawsuit Last month filed a lawsuit against the Biden administration of the Texas Medical Association.
California already has something similar to the Biden rule in effect
The lawsuit alleges that in some states, such as California, there have been strategies similar to the rules the Biden team wrote, recent research shows that the payout ratio is decreasing. Cite that data and a survey of the California Medical Association, the lawsuit says insurers now have an incentive to end contracts with higher-paying in-network providers or force them to accept lower rates, because out-of-network providers will then be subject to the same lower base rate.
Jack Hoadley, of the Georgetown University Health Policy Institute, says results can run one of two ways depending on whether insurers or providers have more power in a particular market or not. are not.
“You have some markets where you have a dominant insurance company, and they can say to the providers, ‘Take it or leave it. Because we represent most insurers, we represent most patients,” Hoadley said.
But elsewhere, there may be a stronger pool of suppliers. “All the anesthesiologists are probably working in a big market, and they can basically say to the insurance companies in that market, ‘Take it or throw it away,’” he said. “.
Hoadley said that whether the network of providers has been reduced remains an open question. Surveys cited in the Texas lawsuit also show increased use of in-network services in some states with similar standards as national law, though it’s not clear if there are many physicians. join the network or more people switch to network providers.
It is also unclear whether the administration will consider lawmakers’ concerns and change the regulations. Some of the Hill employees involved in the response said the process was probably too far away to change and would have to be resolved in court. Others see an opportunity for a last-minute change.
A House staffer noted that more than 70 Democrats complaining to the Democratic White House could have an impact.
“Combined with the whole frenzy of the unexpected payments wars of the past few years and the legal threat, I think there’s still a lot of ball games left,” the employee said.
Health News Kaiser is a national newsroom and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.
