Admin’s Latest Surprise Billing Regulation Stirs Up Controversy

The Biden administration on Sept. 30 issued the latest interim final rule (IFR) to implement the No Surprises Act, and the regulation makes clear that arbitrators will have to use the qualifying payment amount (QPA) — a calculation largely based on median in-network reimbursement rates — as their starting point when settling disputed out-of-network claims. While payer groups praised the rule and provider groups slammed it, some health policy experts say the method outlined for handling payment disputes makes sense — though they caution that it’s unclear how the provider market will ultimately react, or whether costs and premiums will increase due to the No Surprises Act itself.

The IFR stipulates that “when making a payment determination…[arbitrators] must begin with the presumption that the QPA is the appropriate [out-of-network] amount,” according to an HHS fact sheet. “For the independent dispute resolution entity to deviate from the offer closest to the QPA, any information submitted must clearly demonstrate that the value of the item or service is materially different from the QPA.” The IFR also settles other key points such as the scope of federal external review on denied claims and the requirements for calculating good-faith estimates of the cost of care, which providers will soon have to give to patients before a major procedure takes place.

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Peter Johnson

Peter Johnson

Peter has been a reporter for nearly a decade. Before joining AIS Health, Peter covered a wide variety of topics in his hometown of Seattle, where he continues to live. Peter’s work has appeared in publications including The Atlantic and The Stranger. Peter attended Colby College.

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