Surprise Medical Billing

Surprise Medical Billing / en Fri, 02 May 2025 13:42:05 -0500 Mon, 07 Oct 24 16:03:25 -0500 AHA files amicus brief challenging district court decision rendering IDR awards unenforceable /news/headline/2024-10-07-aha-files-amicus-brief-challenging-district-court-decision-rendering-idr-awards-unenforceable The AHA filed an amicus <a href="/amicus-brief/2024-10-04-amicus-brief-guardian-flight-llc-med-trans-corporation-v-health-care-service-corporation">brief</a> Oct. 4 in the U.S. Court of Appeals for the 5th Circuit challenging a decision by the U.S. District Court for the Northern District of Texas, which ruled that independent dispute resolution awards under the No Surprises Act are judicially unenforceable. The AHA argued the district court's decision was inconsistent with longstanding interpretations of the law and would threaten serious harm to providers.&nbsp; &nbsp; "[T]he district court interpreted the NSA to render entire sections of it nugatory," AHA wrote. "There is no need for an IDR process 鈥� or any of the NSA鈥檚 other payment mechanisms 鈥� if nothing requires insurers to render payment upon an IDR determination." The district court鈥檚 interpretation of the No Surprises Act 鈥済ives insurers significant leverage to demand confiscatory discounts from out-of-network providers, as well as to exact across-the-board rate cuts from in-network providers鈥� Both in- and out-of-network providers will thus find themselves perpetually underpaid or even uncompensated for their valuable services, and patients will lose providers and critical care as a result,鈥� the brief notes.&nbsp; The American Medical Association, Federation of 黑料正能量s and the Texas Medical Association joined AHA in the brief. Mon, 07 Oct 2024 16:03:25 -0500 Surprise Medical Billing Amicus Brief: Guardian Flight, L.L.C.; Med-Trans Corporation, v. Health Care Service Corporation /amicus-brief/2024-10-04-amicus-brief-guardian-flight-llc-med-trans-corporation-v-health-care-service-corporation No. 24-10561 IN THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT &nbsp;GUARDIAN FLIGHT, L.L.C.;MED-TRANS CORPORATION, &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Plaintiffs-Appellants, &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; v. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; HEALTH CARE SERVICE CORPORATION, &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Defendant-Appellee. On Appeal from the United States District Court for the Northern District of Texas &nbsp;BRIEF OF AMERICAN HOSPITAL ASSOCIATION, AMERICAN MEDICAL ASSOCIATION, FEDERATION OF AMERICAN HOSPITALS, AND TEXAS MEDICAL ASSOCIATION AS AMICI CURIAE IN SUPPORT OF APPELLANTS AND REVERSAL&nbsp;<table><tbody><tr><td>James E. Tysse Kelly M. Cleary Kristen E. Loveland AKIN GUMP STRAUSS HAUER &amp; FELD LLP 2001 K Street N.W. Washington, D.C. 20006 202-887-4000 jtysse@akingump.com Counsel for Amici Curiae</td></tr></tbody></table> Counsel for Amici Curiae Fri, 04 Oct 2024 13:18:33 -0500 Surprise Medical Billing CMS releases No Surprises Act complaint data, enforcement report /news/headline/2024-08-20-cms-releases-no-surprises-act-complaint-data-enforcement-report The Centers for Medicaid and Medicare Services Aug. 20 released a <a href="https://www.cms.gov/files/document/august-2024-complaint-data-and-enforcement-report.pdf">report</a> presenting data on complaints and enforcement efforts by the agency concerning title XXVII of the Public Health Service Act, which includes both the surprise billing and price transparency provisions of the No Surprises Act. As of June 30, 2024, CMS received more than 16,000 complaints and closed 12,700 with 400 complaints with PHS violations. In total the agency reported over $4 million in restitution for closed cases. Top complaints against plan issuers include non-compliance with Quality Payment Amount requirements, late payment after independent resolution determination, and non-compliance with 30-day initial payment or notice of denial payment requirements. Top complaints against providers relate to surprise bills and good faith estimates. Tue, 20 Aug 2024 14:52:26 -0500 Surprise Medical Billing Appeals court affirms district聽court decision invalidating provisions in No Surprises Act聽 /news/headline/2024-08-05-appeals-court-affirms-district-court-decision-invalidating-provisions-no-surprises-act The 5th Circuit Court of Appeals Aug. 2 <a href="https://www.ca5.uscourts.gov/opinions/pub/23/23-40217-CV0.pdf">affirmed</a> a district court's decision to set aside certain regulations implementing the No Surprises Act. In particular, the decision invalidates regulatory provisions governing how arbitrators are to weigh the qualifying payment amount in arbitration proceedings.&nbsp;&nbsp;&nbsp;鈥淸N]othing in the Act instructs arbitrators to weigh any one factor or circumstance more heavily than the others, nor does the Act authorize the Departments to superimpose regulatory rules on the clear statutory mandate,鈥� the 5th&nbsp;Circuit explained. 鈥淭he Final Rule therefore exceeds the Departments鈥� authority.鈥� Also using language that the AHA repeatedly offered in its briefing, the court of appeals held:&nbsp;鈥淏y telling the arbitrators that they must consider the QPA before all other factors, the Departments place a thumb on the scale in favor of the insurer-determined QPA in derogation of the other congressionally mandated factors. It would distort the statutory scheme for the Departments to impose such an extrastatutory requirement here.鈥�The AHA had long advocated for this position, including in an <a href="/amicus-brief/2022-10-20-amicus-brief-aha-ama-brief-supports-no-surprises-act-dispute-resolution-challenge">amicus brief</a> in 2022 and a <a href="/legal-documents/2021-12-10-hospital-and-physician-groups-file-lawsuit-over-no-surprises-act-final">lawsuit</a> against federal agencies in 2021. Mon, 05 Aug 2024 15:37:38 -0500 Surprise Medical Billing AHA Senate Statement on What Can Congress Do to End the Medical Debt Crisis in America /testimony/2024-07-10-aha-senate-statement-what-can-congress-do-end-medical-debt-crisis-america Statement of the 黑料正能量 Association for the Committee on Health, Education, Labor &amp; Pensions of the United States Senate 鈥淲hat Can Congress Do to End the Medical Debt Crisis in America?鈥� July 11, 2024 &nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners 鈥� including more than 270,000 affiliated physicians, 2 million nurses and other caregivers 鈥� and the 43,000 health care leaders who belong to our professional membership groups, the 黑料正能量 Association (AHA) writes to share the hospital field鈥檚 comments on medical debt. While we appreciate Congress鈥檚 interest in addressing medical debt, we encourage policymakers to do more to prevent patients from incurring this type of debt, rather than focusing on credit reporting and alleviating acquired debt.<h2>OVERVIEW OF MEDICAL DEBT</h2>More Americans than ever are dealing with medical debt, a consequence of patients not paying some or all their health care bills, despite benefiting from the highest levels of insurance coverage in history. Unlike other types of debt, medical debt can be unexpected, due to an accident or illness. These debts can impact patients鈥� abilities to pay for necessities, including food, clothing and household items, and can result in patients using savings or loans to address their medical debt. Recent polling by the KFF found that 鈥�41% of adults have health care debt according to a broader definition, which includes health care debt on credit cards or owed to family members.鈥�1 The survey also showed that:<ul><li>U.S. residents owe at least $220 billion in medical debt.</li><li>Approximately 14 million people (6% of adults) in the U.S. owe over $1,000 in medical debt.</li><li>About three million people (1% of adults) owe medical debt of more than $10,000.</li></ul>Hospitals and health systems are very concerned about patients鈥� medical debt. While health insurance is intended to be the primary mechanism to protect patients from unexpected and unaffordable health care costs, for too many that coverage is either unavailable or insufficient. Trends in health insurance coverage that are driving an increase in medical debt include inadequate enrollment in comprehensive health care coverage, growth in high-deductible and skinny health plans that intentionally push more costs onto patients and misleading health plan practices that confuse patients鈥� understanding of their coverage. These gaps in coverage leave individuals financially vulnerable when seeking medical care. The primary causes of medical debt include the following.<ul><li>There are still too many uninsured Americans. Affordable, comprehensive health care coverage is the most important protection against medical debt. While the U.S. health care system has achieved higher coverage rates over the past decade, gaps remain.</li><li>High deductibles subject many Americans to cost-sharing they cannot afford. High-deductible plans are designed to increase patients鈥� financial exposure through high cost-sharing in exchange for lower monthly premiums. Yet many individuals enrolled in high-deductible plans find they cannot manage their portion of health plan expenses. A Federal Reserve report found that 37% of adults could not afford a $400 emergency, an amount $1,000 less than the average general annual deductible for single, employer-sponsored coverage.2</li><li>Certain health plans provide inadequate benefits that frequently lead to surprise gaps in coverage. Short-term, limited-duration health plans and health-sharing ministries cover fewer benefits and include few to no consumer protections, such as required coverage of pre-existing conditions and limits on out-of-pocket costs. Patients with these types of plans often find themselves responsible for their entire medical bill without help from their health plan, including critical services such as emergency medical and oncology care. These denials can lead to an accumulation of significant medical debt.3</li><li>Complex health plan benefit design and misleading marketing can expose patients to unexpected costs. Many health plans have complex benefit designs that are not transparent to patients, such as what is covered pre-deductible, the interaction between point-of-service copays, coinsurance and deductibles, and poor communication and education about what the plan covers. For example, a recent National Association of Insurance Commissioners report found significant gaps and inconsistencies in how insurers share information about pre-deductible, no-cost-sharing preventive services with their members, resulting in a 鈥渕eaningful barrier to effective understanding and use of preventive service benefits.鈥�4</li></ul><h2>HOSPITALS AND HEALTH SYSTEMS ADDRESSING DEBT</h2>Hospitals are the only part of the health care sector that provide services to patients regardless of their ability to pay. They underscore that commitment by offering financial and other assistance, including helping patients qualify for federal and state health care programs, such as Medicaid. In doing so, patients can receive regular preventive care, not just episodic care for serious injuries or illnesses. In addition, hospitals absorb billions of dollars of losses for patients who cannot pay their bills, mainly due to inadequate commercial insurance coverage; in 2020, the latest figure available, hospitals provided more than $42 billion in uncompensated care.5This is why hospitals are staunch supporters of ensuring everyone is enrolled in some form of comprehensive coverage. However, we appreciate that closing the remaining coverage gaps may be a longer-term solution and that more immediate steps can be taken. To that end, the AHA has routinely developed patient billing guidelines to help prevent patients from incurring medical debt. The AHA鈥檚 Board of Trustees adopted the most recent <a href="/standardsguidelines/2020-10-15-patient-billing-guidelines" target="_blank">set of guidelines</a> in 2020, which reaffirm the hospital field鈥檚 commitment to:<ul><li>Treating all people equitably, with dignity, respect and compassion.</li><li>Serving the emergency health care needs of all, regardless of a patient鈥檚 ability to pay.</li><li>Assisting patients who cannot pay for part or all the care they receive.</li></ul>Tax-exempt hospitals are also subject to a federal statute that requires written financial assistance and debt collection policies. These hospitals must wait at least 120 days after sending the initial bill to initiate extraordinary collections actions, notify the patient at least 30 days before taking the collections action and allow patients to submit financial aid applications for up to 240 days following the initial bill.Several of the AHA鈥檚 guidelines directly address medical debt, including encouraging hospitals to forego adverse credit reporting of outstanding patient bills. So far, nearly 2,800 hospitals and health systems have affirmed their commitment to the guidelines, and the AHA revisits them regularly for updates.Some hospitals are taking additional steps to help all eligible patients afford their medical bills, including using programs originally intended for the uninsured. These 鈥減resumptive eligibility鈥� endeavors include proactively screening patients for financial assistance eligibility, regardless of insurance coverage or whether a patient has completed a financial aid application. The goal is to limit the need for hospitals to seek repayment by reducing patients鈥� financial liability to a more affordable amount.<h2>FEDERAL OVERSIGHT OF MEDICAL DEBT</h2>Policymakers at the federal level have acted to address the burden of medical debt through statutory changes, such as collection practices of tax-exempt hospitals, as well as those made through the Fair Debt Collection Practices Act, as overseen by the Consumer Financial Protection Bureau (CFPB), which impact how medical debt is displayed on credit reports. Recently, CFPB issued medical debt payment products and medical debt collection practices requests for information and a proposed rule to ban credit reporting agencies from incorporating medical debt when calculating credit scores.While hospitals and health systems are assisting patients with their bills, policymakers must do more to prevent them from incurring these debts. Rather than focusing on debt relief grants or putting additional administrative burdens on providers, Congress must ensure patients can access comprehensive, affordable health insurance products.Some of these suggested changes include:<ul><li>&nbsp;Restricting the sale of high-deductible health plans to only those individuals with the demonstrated means to afford the associated cost-sharing.</li><li>Prohibiting the sale of health-sharing ministry products and short-term limited-duration plans that go longer than 90 days.</li><li>Lowering the maximum out-of-pocket cost-sharing limits.</li><li>Eliminating the use of deductibles and co-insurance, and instead relying solely on flat co-payments which are easier for patients to anticipate and for providers to administer.</li><li>Removing providers from the collection of cost-sharing by requiring health plans to collect directly from their enrollees the cost-sharing payments they impose. This approach would eliminate most patient bills from providers altogether.</li></ul>Congress could also do more to improve health literacy by funding health navigators, community health workers and financial advisors to assist patients in selecting appropriate health insurance products.<h2>CONCLUSION</h2>Thank you for your consideration of the AHA鈥檚 comments on issues related to medical debt. We look forward to continuing to work with you to address these important topics on behalf of our patients and communities.__________1 <a class="ck-anchor" id="https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/" href="https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/">https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/</a>&nbsp; 2 <a class="ck-anchor" id="https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm" href="https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm">https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm</a> 3 <a class="ck-anchor" id="https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/" href="https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/">https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/</a>&nbsp; 4 <a class="ck-anchor" id="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/" href="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/">https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/</a>&nbsp; 5 <a class="ck-anchor" id="/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf" href="/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf">/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf</a>&nbsp; &nbsp; Wed, 10 Jul 2024 12:11:44 -0500 Surprise Medical Billing Rel 24.4 Landing <h2>Professional Membership Groups</h2>Your organization鈥檚 membership in the 黑料正能量 Association connects you to the nation鈥檚 most powerful advocacy organization for hospitals. But did you know that the AHA has a number of professional membership societies designed to support specific areas of hospital operations? These individual membership organizations offer tremendous opportunities for education, collaboration, and access to valuable tools and resources all designed to advance operational excellence within your organization.Membership in these groups can help your teams with issues such as:<ul><li>Navigating supply chain challenges</li><li>Maintaining a safe and healing health care delivery environment</li><li>Keeping up with new standards for infection prevention</li><li>Navigating risk at a time of increasing uncertainty</li><li>Building your organization鈥檚 brand and market share</li><li>Convincing hesitant populations to get the COVID-19 vaccine</li></ul>Read on to learn more about these groups. We鈥檝e also designed a form to make it easy for you to get more information for yourself or for others within your organization. Complete the form to the right with the names and contact information of the individuals you believe could benefit from access to these valuable professional membership societies. Thu, 18 Apr 2024 20:26:26 -0500 Surprise Medical Billing Rel 24.4 Event /education-events/rel-244-event The hospital and health system field strongly supports protecting patients from surprise medical bills. The AHA is pleased to present an afternoon of review and analysis of Congress rejected approaches that would impose arbitrary rates on providers, which could have significant consequences far beyond the scope of surprise medical bills and impact access to hospital care. We also applaud Congress for rejecting attempts to base rates on public payers, including Medicare and Medicaid, which historically pay far less than the cost of delivering care. We believe this legislation is an important step forward in protecting patients. Thu, 18 Apr 2024 19:46:32 -0500 Surprise Medical Billing AHA Comments on No Surprises Act IDR Process Proposed Rule /lettercomment/2024-02-05-aha-comments-no-surprises-act-idr-process-proposed-rule February 5, 2024<table><tbody><tr><td>The Honorable Chiquita Brooks-LaSure Administrator Center for Medicare &amp; Medicaid Services Department of Health &amp; Human Services</td><td>The Honorable Lisa M. Gomez Assistant Secretary Employee Benefits Security Administration Department of Labor</td></tr><tr><td>Douglas W. O鈥橠onnell Acting Commissioner Internal Revenue Service Department of Treasury</td><td>&nbsp;</td></tr></tbody></table> Submitted ElectronicallyRe: Federal Independent Dispute Resolution Operations, CMS鈥�9897鈥揚, November 3, 2023, Vol. 88, No. 212.Dear Administrator Brooks-LaSure, Acting Commissioner O鈥橠onnell and Assistant Secretary Gomez:On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners 鈥� including more than 270,000 affiliated physicians, 2 million nurses and other caregivers 鈥� and the 43,000 health care leaders who belong to our professional membership groups, the 黑料正能量 Association (AHA) appreciates the opportunity to comment on the proposed rule related to the operations of the Independent Dispute Resolution Process (IDR) established by the No Surprises Act (NSA).AHA strongly supports Congress鈥� approach to protecting patients from unexpected medical bills through the passage of the NSA. Patients are protected against unexpected medical bills for certain types of health care services when provided by out-of-network providers, and Congress allowed for providers and payers to work collaboratively to determine reimbursement; the IDR process is included should negotiations between the two parties break down.While we support the underlying goals and structure of the NSA, we have raised concerns over implementation of the statute particularly regarding the IDR process.1 A high-functioning and unbiased IDR process is crucial for fully realizing the NSA鈥檚 patient protections, as inappropriate reimbursement can impact providers鈥� ability to offer services or offer them in the timeframe or of the quality that patients deserve. We are pleased that the proposals in this rule address many of the areas of concern to hospitals and health systems and, if finalized, should significantly improve the process.Specifically, the AHA supports the following proposals:<ul><li>Enabling parties to include (or batch) all items and services associated with a single patient encounter, rather than needing to adjudicate individual line items.</li><li>Requiring payers to share additional information with providers, including information on whether the claim is eligible for the federal IDR process and other information supplied through claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs).</li><li>Creating a process for the government to assist IDR entities in reducing any backlogs in processing disputes.</li><li>Requiring parties to document in the federal portal the open negotiation process.</li><li>Requiring that payers subject to the IDR process register with the departments and provide general information regarding the applicability of the IDR process to items or services covered by the plan.</li></ul>At the same time, we are concerned that some of the proposals are inadequate to substantially improve the IDR process. These include:<ul><li>Limiting batched claims to 25 line items, especially in the context of a single episode of care.</li><li>Barring providers from batching claims for self-insured employers by third-party administrators.</li><li>Charging high fees and only reducing for non-initiating parties the fees for claims found ineligible.</li></ul>While the proposed rule includes many important provisions, several issues critical to the functionality of the IDR process need to be addressed. Of greatest importance are how payers calculate the qualifying payment amount (QPA) and the information regarding these calculations being made available to providers and IDR entities. QPAs are one of the statutorily mandated factors for IDR entities to consider and, as such, QPA accuracy and transparency is fundamental to a functioning and efficient IDR process.In addition, the departments do not fully address how they intend to conduct oversight in certain situations, such as when a health plan fails to pay a provider, subsequent to an IDR determination. Hospitals and health systems report that payers consistently are not complying with IDR determinations, including one member who testified before Congress earlier this year that payers had made timely payment in only one-third of the disputes decided in the health system鈥檚 favor.2 The health system was still owed $40 million in reimbursement for disputes that had been decided but for which the payer had not remitted payment within the required timeframe. This behavior cannot persist. The delay or loss of millions of dollars in reimbursement only harms patients by starving providers of the resources they need to deliver care. Indeed, the loss described above has contributed to this health system operating with negative margins.We have long urged greater oversight of payers as it relates to the NSA. It is deeply concerning that the departments have not completed a single audit of payers when the law has been in effect for nearly two full years. For example, should one of the audits conclude that a payer inappropriately suppressed its QPAs, how do the departments envision remedying this situation if hundreds (or more) IDR disputes have been impacted?These delays in oversight have contributed to a fundamentally imbalanced situation where payers are able to inappropriately withhold providers鈥� revenue 鈥� the revenue they need to finance patient care 鈥� knowing that the likelihood of being caught or challenged is low. All of the control rests with the payer; all of the risk resides with the provider and, ultimately, the patient. As such, we were unsurprised to see analysis of the most recent National Health Expenditure data from the Centers for Medicare &amp; Medicaid Services鈥� (CMS) actuaries. Specifically, they found 鈥渢he net cost of private health insurance, which represents the difference between revenues received by private health insurers and the amounts paid by those insurers for medical care incurred, increased 8.0 percent in 2022,鈥� and that 鈥溾€ncreases in net gains or profits for insurers contributed to faster price growth in the net cost of insurance.鈥�3 While we expect multiple factors contributed to insurers鈥� increased profits, we point to the concerns we have long raised about the ability of payers to take advantage of the NSA to withhold appropriate revenue from providers to enrich themselves and not return the savings to consumers.We recognize that the departments are working on additional rulemaking related to the NSA, and we urge the departments to address these issues through that process.Our detailed comments on the proposals in this rule follow.<h2>BATCHING OF CLAIMS</h2>The departments propose several changes to when and how providers may batch items and services in a single dispute. We focus our comments on three particular aspects of these proposals:<ul><li>Batching all items and services for a single patient encounter.</li><li>Limiting batches to no more than 25 items and services.</li><li>Requiring that batching be done at the employer level for self-insured claims, as opposed to at the insurer or third-party administrator level.</li></ul>First, the AHA strongly supports the proposal to allow providers to batch all items and services associated with a single patient encounter, something for which we have long advocated. Our longstanding concerns over the existing, narrow definition of 鈥渋tem or service鈥� for purposes of batching claims for IDR disputes has made the IDR process effectively unworkable for hospitals. Facility claims routinely include more than one item or service. Requiring providers to break up claims and adjudicate line items individually creates an untenable situation, no matter what the provider decides to do. Disputing all line items would be cost-prohibitive, given the fees associated with the IDR process; selecting only one or several line items to adjudicate forces the provider to forgo potential reimbursement for the full scope of services provided, thereby complicating adjudication of a dispute for the IDR entity, who is forced to evaluate only a partial claim.For the same reasons, we urge the agency not to finalize the proposal to limit the number of line items to 25 (or 50). It is not uncommon that a facility-based episode of care, especially for an emergency medical condition that requires substantial post-stabilization care, will include numerous individual items and services. While many claims would likely have less than 25 individual items and services, some of the most complex 鈥� and expensive 鈥� care may not. One hospital system shared that, for a single episode of care, their outpatient emergency claims range between two and 85 line items.Forcing providers to arbitrarily break up claims to submit to the IDR process places them exactly back in the situation they are in today. As a result, we expect this proposal would not meet the finding of the federal court in Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK, which found the department failed to consider 鈥渂roader batching criteria that would give providers increased opportunity to bring their claims to arbitration.鈥� An arbitrary limit of 25 lines would certainly decrease a provider鈥檚 ability to bring many full claims to arbitration.We urge the departments to either refrain from limiting the number of line items that may be included in a batch or, as an alternative, exempt facility-based claims from this policy. A possible, though less favorable, further alternative would be to cap batched claims to 100 items and services, as this would likely capture most facility-based claims in whole.Finally, we continue to oppose the departments鈥� position that claims for patients with self-funded coverage should be batched at the employer level and not at the level of the third-party administrator administering the benefits. While we recognize that the employer is ultimately responsible for reimbursement of claims, most employers contract with their third-party administrators to manage these functions and, as such, it is the administrator, and not the employer, that is setting the payment amount, remitting the payment and participating in any disputes that progress to the IDR process. We therefore urge the departments to reconsider this policy, as it severely limits the ability of providers to batch items and services that are for all meaningful purposes from the same payer. A less-preferred alternative would be to require that claims be batched by employers when the employers themselves are adjudicating the claim and by third-party administrators when those entities are adjudicating the claims.However, if this policy is finalized, we urge the departments to require the payer to include the employer identification number on the remittance advice. Otherwise, providers may not necessarily know with which employer the claim is associated. Tracking down this information after the fact adds burden on all parties, including IDR entities that receive ineligible claims, due to a provider鈥檚 lack of knowledge about the employer.<h2>BUNDLING</h2>The departments propose that items and services that meet the definition of a bundled payment arrangement (e.g., DRG) may be submitted and considered as a single payment determination, and the IDR entity must make a single payment determination for the multiple qualified IDR items and services included in the bundled payment arrangement. The AHA supports this proposal. However, to ensure consistency, we ask that the departments specify that Medicare bundling rules (MS-DRGs) are to be used by providers and IDR entities.<h2>INFORMATION SHARING BETWEEN PLANS AND PROVIDERS</h2>The departments propose to require that payers include additional information in certain communications with providers. Specifically, payers would be required to include CARCs and RARCs when they provide paper- or electronic-remittance advice to a provider that does not have a contractual relationship with the payer. These codes would be used to clearly communicate to the provider whether the claim for the furnished item or service is, or is not, subject to the NSA provision, as well as eligible for the IDR process. In addition, payers would be required to provide information such as the legal business name of the health plan, the health plan鈥檚 sponsor and the health plan sponsor鈥檚 IDR registration number. Payers would also be required to include in a disclosure to the provider a statement that providers must notify the departments to initiate the open negotiation period (described below).The AHA strongly supports these proposals. One of the biggest challenges for providers has been obtaining sufficient information about claims, including whether or not a claim is eligible for the IDR process. While the departments established the CARC and RARC codes to facilitate this information sharing, hospitals and health systems report that payers are not consistently using them. We believe this proposal would go a long way towards reducing the volume of ineligible disputes. However, we urge the departments to incentivize payers to consistently use electronic remittance advice, rather than paper versions. Paper versions add complexity and cost for providers to manage. Should payers use a paper remittance, we request that the departments give providers additional time after the initial payment or notice of denial to open negotiations.<h2>OPEN NEGOTIATION PROCESS</h2>The departments propose changes to the open negotiation process to improve communication and information exchanges between disputing parties. The current statutory and regulatory requirements establish a 30-business-day open negotiation period between disputing parties to resolve payment disputes prior to initiating the IDR process and incurring fees. The departments are proposing new requirements to encourage good faith negotiations to occur during this window. Specifically, the departments propose to require that an interested party use the federal IDR portal to communicate to both the other party and to the departments about the intent to negotiate. This proposal also would include new content elements for the open negotiation notice to help the affected parties identify the item or service, the reason for the denial of payment and the initial payment amount. In addition, the rule would require that the party on the receiving end of the open negotiation notice acknowledge its receipt of the notice by issuing a response, which also would be filed in the federal IDR portal and shared with the departments.The AHA supports these proposals. Failure by plans to meaningfully engage in the open negotiation process has rendered it ineffective. We believe these proposals will encourage payers to respond to providers鈥� efforts to negotiate, which should in turn result in more claims disputes being resolved without the need for IDR. In order for this to have the intended effect, however, the departments must set clear expectations for payers regarding monitoring of compliance and implications for failure to engage, including any penalties.<h2>ADMINISTRATIVE FEES</h2>The departments propose to streamline the collection of the IDR administrative fees from the disputing parties. The departments would collect the administrative fees directly from the disputing parties rather than have the IDR entity collect the fees on behalf of the departments. The proposal would require that the initiating party pay the administrative fee within two business days after the IDR entity selection, while the non-initiating party would pay within two days of the notice of receiving the IDR eligibility determination. If the initiating party fails to pay the administrative fee, the dispute would be closed for non-payment and neither of the disputing parties would owe the administrative fee. If the non-initiating party fails to pay the administrative fee, the party鈥檚 offer would not be considered received. The rule proposes to charge both parties a reduced administrative fee for low dollar disputes when the highest offer made during the open negotiation period by either party was less than a predetermined threshold.Lastly, the rule outlines the administrative fees for 2025:&nbsp;<ul><li>Full administrative fee per party per dispute would be $150.</li><li>Reduced administrative fee for low-dollar disputes would be $75 for both parties.</li><li>Reduced administrative fee for non-initiating parties in disputes found ineligible for IDR would be $30.</li></ul>The AHA agrees with the proposals to have the departments collect the relevant fees and the handling of non-payment by the non-initiating party. However, we remain concerned that the amount of the fees may be cost-prohibitive, especially depending on the final rules related to batching. We encourage the departments to reduce the fees for at least twelve months after any new batching rules go into effect, such that the departments can better evaluate the cost of administering the IDR process under these new rules.<h2>IDR ELIGIBILITY DETERMINATIONS PROCESS</h2>The departments propose several new requirements in addition to the mandatory use of the CARC and RARC codes to address concerns that numerous claims filed through the IDR process are proven to be ineligible, wasting IDR entities鈥� time and resources. First, the rule would establish new timelines for evaluating and communicating to interested parties whether or not a claim is eligible for the IDR process. The rule would require IDR entities to determine a claim鈥檚 eligibility within five business days of the IDR entity selection and to notify the disputing parties and the departments. The disputing parties would then have five business days to submit additional information requested by the IDR entity. The rule also proposes that the departments establish a departmental eligibility review process to determine eligibility during periods of systemic delays or other extenuating circumstances. This review process would be limited only to determining IDR eligibility and not to payment determinations. The AHA supports these proposals. However, we also request that the departments maintain the existing grace period for initiating parties to resubmit a claim that is wrongfully determined to be ineligible.<h2>IDR REGISTRY</h2>The rule would require that payers subject to the IDR process register with the departments and provide general information regarding the applicability of the IDR process to items or services covered by the plan. Payers would receive an IDR registration number upon submission of the information. The proposal is intended to make it easier for interested parties to determine if their dispute is eligible for the IDR process. In addition, the departments believe this proposal would help interested parties distinguish types of coverage the payer may provide or administer via different plans. The AHA supports this proposal.We appreciate your consideration of these issues and look forward to working with your teams to improve the implementation of the IDR process. Please contact me if you have questions or feel free to have a member of your team contact Ariel Levin, AHA鈥檚 director of coverage policy, at <a href="mailto:alevin@aha.org" target="_blank" title="Email addres ">alevin@aha.org</a>.Sincerely,/s/Stacey Hughes Executive Vice President&nbsp; Government Relations and Public Policy__________ 1 AHA Feb. 15, 2023, letter to NSA tri-departments: Centers for Medicare &amp; Medicaid Services, Employee Benefits Security Administration and the Department of Treasury. 2 <a href="https://gop-waysandmeans.house.gov/wp-content/uploads/2023/09/Budzinski-Testimony.pdf" target="_blank" title="Budzinski Testimony PDF">https://gop-waysandmeans.house.gov/wp-content/uploads/2023/09/Budzinski-Testimony.pdf</a> 3 <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.01360" target="_blank" title="Health Affairs document ">https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.01360</a> Mon, 05 Feb 2024 13:19:45 -0600 Surprise Medical Billing Agencies to reopen comment period for No Surprises Act IDR rule /news/headline/2024-01-18-agencies-reopen-comment-period-no-surprises-act-idr-rule The departments of Health and Human Services, Labor and the Treasury will <a href="https://public-inspection.federalregister.gov/2024-01072.pdf" target="_blank">reopen</a> the public comment period for their <a href="/news/news/2023-10-27-cms-releases-proposed-rule-improve-no-surprises-act-idr-process" target="_blank">proposed rule</a> to improve the No Surprises Act independent dispute resolution process for 14 days beginning Jan. 22 to provide additional time for interested parties to comment. Thu, 18 Jan 2024 15:11:41 -0600 Surprise Medical Billing CMS finalizes changes to No Surprises Act administrative and IDR fees /news/headline/2023-12-19-cms-finalizes-changes-no-surprises-act-administrative-and-idr-fees The departments of Health and Human Services, Labor and the Treasury Dec. 18 released a <a href="https://public-inspection.federalregister.gov/2023-27931.pdf">final rule</a> that increases the administrative fee for disputes initiated under the No Surprises Act independent dispute resolution process from $50 to $115 per party per dispute. The departments also finalize an increase to the fee range for certified IDR entities to $200-$840 for single determinations and $268-$1,173 for batched determinations. IDR entities will have discretion to increase the fee for batched disputes with more than 25 line items at a rate of $75-$250 per increment of 25 line items. The changes take effect for disputes initiated on or after 30 days after publication of the final rule in the Federal Register, which is anticipated to occur within the next week. These fees will remain in effect until changed by subsequent notice-and-comment rulemaking.&nbsp; &nbsp; In August, a federal judge in Texas <a href="/news/headline/2023-08-07-federal-judge-strikes-down-no-surprises-act-idr-fee-increase-batching-restrictions-cms-suspends-idr">ordered</a> the agencies to vacate nationwide a federal fee increase and batching rule for the IDR process for certain out-of-network providers and group health plans because they violate the Administrative Procedures Act鈥檚 notice-and-comment requirement. &nbsp; &nbsp; AHA Oct. 26 <a href="/lettercomment/2023-10-26-aha-responds-no-surprises-act-independent-dispute-resolution-proposed-rule">supported</a> the proposal to use the Administrative Procedure Act process to establish the fees, but opposed, among other provisions, the fee increases and use of an inflationary adjustment for future increases.&nbsp; &nbsp; Tue, 19 Dec 2023 15:01:00 -0600 Surprise Medical Billing