Modern Healthcare Source Article

TARA BANNOW & JESSIE HELLMANN  

October 01, 2021

Providers are crying foul about a regulation from the Biden administration that lays out the process they can use to settle out-of-network billing disputes with payers.

The rule, released Thursday by the Centers for Medicare and Medicaid Services, is the next step in its implementation of the surprise billing ban passed last year by Congress.

Payers praised the regulation as the "right approach," while providers swiftly denounced it as a "miscue" arbitrarily favoring insurers. At issue is the part of the regulation that lays out the independent dispute resolution process used when there is a disagreement between providers and payers over the fair price for an out-of-network service.

In the IDR process, both the insurer and provider tell an arbiter what they think the appropriate rate for an out-of-network service is. CMS directs the arbiter to presume the "qualifying payment amount," which is usually an insurer's median contracted rate for the same service in a geographic area, is the "appropriate" rate and pick the offer closest to that.

In the providers' minds, that gives insurers too much leverage.

"It goes way beyond protecting patients. It protects insurance companies and gives primary credence to their point of view and data," said Chip Kahn, CEO of Federation of American Hospitals. FHA is a trade group that represents for-profit hospitals.

 Continue reading►