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Life Health > Health Insurance

'Surprise Bill' Arbitrators Should Not Send Surprise Bills: Regulators

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What You Need to Know

  • Certified independent dispute resolution entities are supposed to arbitrate disputes between health insurers and health care providers over out-of-network emergency care bills and certain other out-of-network bills.
  • Some states already have comparable versions of the No Surprises Act arbitration system in place.
  • Federal officials believe typical arbitrators participating in the state No Surprises systems are charging $300 to $600 per arbitration.

Federal regulators are warning the arbitrators who handle No Surprises Act medical billing dispute mediators not to send out surprise bills of their own.

Officials at the Center for Consumer Information & Insurance Oversight talk about medical bill arbitrators’ fees in a batch of technical guidance issued Thursday.

Technical guidance does not have the weight of a full-fledged regulation, but it does show how agency officials are interpreting laws and regulations.

The No Surprises Act

CCIIO is part of the Centers for Medicare & Medicaid Services, which, in turn, is part of the U.S. Department of Health and Human Services.

CCIIO is working with other agencies, including the Internal Revenue Service and the U.S. Department of Labor’s Employee Benefits Security Administration, to write the rules needed to implement the No Surprises Act.

The best-known parts of the act, set to take effect Jan. 1, 2022, apply to patients enrolled in managed care health plans who get emergency care out of their plans’ provider networks, or who go to in-network hospitals and end up seeing some health care professionals such as radiologists who are outside their network.

The act requires providers to bill those patients at reasonable rates.

In the past, insurers, agents and brokers typically referred to the issue by the name “balance billing.” Balance billing refers to situations in which a health plan pays part of a health care provider’s bill, and the provider can then bill the patient for the rest of the charges.

The new guidance is a companion to a 520-page interim final regulation that describes how a new dispute resolution system, or arbitration system, will handle hard-to-solve conflicts between insurers and providers over care prices.

The American Medical Association and the American College of Emergency of Physicians have argued that the system will be too tough on providers. The AMA described the system as “a surprise gift to the insurance industry,” because it starts with the assumption that a payment amount set by a group of health insurers might well be the right amount.

Certified IDR Entities

Arbitrators called “certified independent dispute resolution” entities, or certified IDR entities, are supposed to help providers and insurers resolve differences about what out-of-network emergency care, and care provided by out-of-network providers in in-network hospitals, should cost.

CCIIO says it and other agencies looked at what arbitrators in states with local bans on surprise billing are charging.

The range was $270 to $6,000.

CCIIO says a certified IDR entity should charge between $200 and $500 for its assistance.

“This range was selected to keep administrative costs reasonable, thereby reducing the potential for excessive certified IDR entity fees that could result in inflated health care and insurance costs that could ultimately be passed on to consumers,” CCIIO says in the guidance.

HHS and other agencies involved in implementing the No Surprises Act “are of the view that a fixed fee is the best approach to ensure a certified IDR entity’s time is compensated based on the level of effort, that administrative costs are reasonable, and that the federal IDR process remains accessible,” CCIIO says.

CCIIO says a certified IDR must provide any services associated with No Surprises Act arbitration, such as copy documents, into the certified IDR entity fee of $200 to $500.

Federal agencies plan to update the fee range every year.

(Image: Adobe Stock)


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