Background: The No Surprises Act, effective January 1, 2022, bars health providers from billing patients more than what they would be reimbursed for in-network services in emergencies or other circumstances when out-of-network providers are used. In cases where employer health plans and providers are unable to resolve payment disputes, the IDR process is used. This process was the focus of the second interim final rule.
HR Policy applauded the Biden administration for placing an emphasis on the qualifying payment amount, i.e., the median in-network rate for the same or similar services in a geographic region (QPA) when determining the out-of-network provider payment employers will have to make. HR Policy’s comments noted that using the QPA as the primary factor “encourages predictable outcomes, which will reduce the use of the IDR process over time and the associated administrative fees borne by the parties, while providing equitable and clear standards for when payment amounts may deviate from the QPA.”
Our comments also suggested the following:
- Initial payment amount: The Departments should not establish any standards regarding the initial payment employers are required to make.
- Transparency: When initiating the IDR process, providers and facilities should be required to submit, in writing, a description of the good faith efforts the parties engaged in during the 30-day open negotiation period. The Association noted this would prevent parties from circumventing the negotiation process to go immediately to IDR.
Outlook: The Association also provided recommendations to the preamble text to remove language that has served as the basis of legal challenges to the rule. HR Policy will continue to engage with the Biden administration on the rulemakings and any subsequent legal challenges.
