Biden faces health industry fight over new ‘surprise’ billing ban

Groups that have started lobbying the administration include large hospital systems and health insurers, large trade associations, ambulance companies, and private equity-backed physician recruitment firms, including at least one that has been linked to a successful dark money effort that employed dozens of people Millions of dollars for killing a previous surprise bill that was rejected by healthcare providers.

Groups have already spent large amounts of money on lobbying and are expected to step up their efforts soon to put patient advocates on alert as to whether the new safeguards could be watered down during the regulatory process and consumers are still vulnerable to unexpectedly large bills.

“[The Department of Health and Human Services] will have to be really tough, or it’s another slushy law that is supposed to be preventative but completely workable, “said a consumer advocate, who spoke on condition of anonymity because he is in contact with the administration on the matter.

Federal officials are faced with an extensive checklist of issues that need to be resolved in the coming months. The first major deadline of the law is shortly before July. They need to figure out how to ensure that patients don’t unwittingly sign their new protections, monitor and punish providers who violate the ban, and, among other things, put in place a dispute resolution process. The ban is due to come into force in January.

“Parts of the bill are very vague. So dependent on decisions made by [the administration]The ban on surprise billing could be a boon to patients – or it could be catastrophically expensive, “said James Gelfand, lobbyist for the ERISA Industry Committee, which represents large employers.

Surprise bills are usually issued after visits to the emergency room, when patients may be taken to a hospital outside of their care network or are being looked after by a specialist who is not on the network. Even with planned interventions such as operations, patients can unexpectedly be cared for by a specialist outside the network such as an anesthetist.

An estimated one Every fifth patient is affected by a surprise bill after elective surgery, according to a JAMA study last year. And the practice increases health system costs and increases insurance premiums. Curbing surprise bills would save premiums between $ 12 billion and $ 38 billion a study by the USC Schaeffer Center for Health Policy and Economics last fall.

What once appeared to be a simple solution to the problem turned into a two-year problem at last Congress after physicians staff groups – aided in some cases by private equity interests – heavily attacked the initial bipartisan framework for ending surprise bills. Hospitals also fought against the plan they labeled the insurer of choice and pointed to price controls. In order to pass a ban before the last Congress was suspended, lawmakers cleared many of the most sensitive issues.

The final legislation is believed to be kinder to doctors and hospitals than previous versions. Patients are essentially expected to pay their insurer’s network tariff if they are unexpectedly served by an off-network provider. Doctors and insurers are expected to negotiate the remaining fees, and any disputes they cannot resolve will be referred to a mediator.

However, the Biden administration has a job to fill in many of the details, including how insurers should calculate the initial payment to providers outside the network before both sides agree on the final cost. This ultimately has an impact on what patients have to pay out of pocket. Determining this tariff, which is tied to local network costs, is made difficult by the fact that privately negotiated tariffs for health services are often hidden. Doctors are already pushing for higher payments while insurers and employers want to keep them low.

The federal government must also set up an “independent dispute settlement procedure” by the end of the year to handle complaints from providers who claim to have been given low ratings by insurers. The challenge for HHS is to develop a system that will be considered fair but will not become the point of contact for resolving disputes. Policy experts and patient advocates believe that costs will rise.

There are also concerns about how patients can still get large bills for signing a consent form declaring their willingness to be cared for by a specialist outside the network. Congress specifically banned this option from anesthesiologists, pathologists, radiologists, and other specialists who are among the largest sources of surprise bills. However, patient representatives fear possible loopholes.

“The concept of consent brings the consumer back, and that is worrying,” said Patricia Kelmar, director of health campaigns for the US-PIRG consumer protection group. “Consent is a stab in the wall that protects the consumer.”

HHS, which does most of the administrative work on the surprise billing ban, has been calling industry groups for feedback since last month. According to numerous sources that have participated, federal health officials have largely focused these calls on technical details rather than some sensitive issues related to payments and enforcement of the ban.

A department spokesman said that is also the case early to “speculate on the final rulemaking process” but feedback from the calls will provide “a solid foundation for rulemaking based on best practices, transparency, and the needs of all Americans”.

The American College of Emergency Physicians is focused on ensuring that HHS maintains balanced arbitration to resolve payment disputes, a group spokesman said.

“Congress has stipulated in the legal text that all arbitration factors should be weighted equally,” said spokeswoman Laura Wooster. “On the regulatory side, we want to make sure that this is preserved. If it’s not explicitly stated in the regulation, it is.” Over time, it gets easier to get a little lopsided [for insurers]. “

In the meantime, health insurers want to ensure that regulations prevent “bad actors” from playing this system, a spokesman for a top trade group said.

“Solutions that both protect patients and reduce health care costs include regulations prohibiting abuse of the independent dispute resolution process, providing clear guidance on the legally qualified services, and ensuring that payments reflect market conditions and tariffs “said Kristine Grow of America’s Health Insurance Plans.

Regulatory deadlines are fast approaching while some key positions in HHS have not yet been filled by political officials who would have to make some of the toughest decisions to implement the new law.

Health insurance experts like Jack Hoadley, a professor at Georgetown University, said the administration is on a tight schedule to introduce the ban on surprise billing.

“We gave federal agencies a lot of responsibility for a law due in January and the clock is ticking,” said Hoadley.

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