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  • Washington Highlights

    Over 150 House Members Support Revisions to Surprise Medical Billing Rule


    Ally Perleoni, Director, Government Relations

    Over 150 members of the U.S. House of Representatives signed a Dear Colleague letter urging revisions to the interim final rule (IFR) issued on the implementation of the surprise medical billing independent dispute resolution (IDR) process enacted by the No Surprises Act [refer to Washington Highlights, Oct. 1]. The AAMC-supported letter was sent on Nov. 5 to the departments of Health and Human Services, Treasury, and Labor.

    The IFR, issued on Sept. 30, established the federal IDR process that out-of-network providers, facilities, and plans may use to determine a payment rate in the case of a failed open negotiation period. Notably, the rule states that the IDR entity must “begin with the presumption that the Qualifying Payment Amount (QPA) is the appropriate [out-of-network] amount.” The QPA is determined based on the median contracted prices in the area for the same medical service. The rule acknowledges that additional factors in the statute — such as teaching status, patient acuity, and case mix — could be considered. However, to deviate from the QPA as the payment rate, providers must submit evidence that clearly demonstrates the QPA is “materially different” from the appropriate out-of-network rates.

    The letter, which was led by Reps. Thomas Suozzi, JD (D-N.Y.), Brad Wenstrup, DPM (R-Ohio), Ami Bera, MD (D-Calif.), and Larry Bucshon, MD (R-Ind.), urged the departments to reconsider the process outlined in the IFR to ensure that it would “align the law’s implementation with the legislation Congress passed.” According to the letter, “the parameters of the IDR process in the IFR … do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes.”

    Additionally, the letter highlighted the potential impact on patient access to care because the IFR as written “could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks.” It also stated that the IFR could have a “broad impact on reimbursement for in-network services,” which could worsen access issues in rural and urban underserved communities and “exacerbate existing health disparities.”

    “We urge you to revise the IFR to align with the law as written by specifying that the certified IDR entity should not default to the median in-network rate and should instead consider all of the factors outlined in the statute without disproportionately weighting one factor,” the letter concluded.