Surprise Billing Ban’s Price Calculation May Lock In High Rates

The Biden administration on July 1 released an interim final rule (IFR) that launches implementation of the No Surprises Act, the December 2020 legislation that banned balance billing by health care providers in most cases. Experts say the rule is good for consumers but that the mechanism used to calculate billing rates could lock in high prices — though they aren’t yet sure whether the arbitration mechanism that will be used to adjudicate disputed claims will ultimately benefit providers or payers in the long term.

The IFR, which is subject to a 60-day public comment period, “is expected to go into effect as written,” according to a Health Affairs blog post by authors including Katie Keith, a health care attorney and research professor at Georgetown University’s Center on Health Insurance Reforms. According to the post, “topics in this IFR include patient cost-sharing protections, notice and consent standards for waivers, rules for calculating the qualifying payment amount (QPA), disclosure requirements, and complaints processes, among other standards.” The authors also expect additional rules to be published in the months ahead of the No Surprises Act’s Jan. 1, 2022, implementation date.

Loren Adler, an associate director at the USC-Brookings Schaeffer Initiative for Health Policy, says that the provisions of the IFR are logical next steps for HHS.

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Peter Johnson

Peter Johnson

Peter has worked as a journalist since 2011 and has covered health care since 2020. At AIS Health, Peter covers trends in finance, business and policy that affect the health insurance and pharma sectors. For Health Plan Weekly, he covers all aspects of the U.S. health insurance sector, including employer-sponsored insurance, Medicaid managed care, Medicare Advantage and the Affordable Care Act individual marketplaces. In Radar on Drug Benefits, Peter covers the operations of (and conflicts between) pharmacy benefit managers and pharmaceutical manufacturers, with a particular focus on pricing dynamics and market access. Before joining AIS Health, Peter covered transportation, public safety and local government for various outlets in Seattle, his hometown and current place of residence. He graduated with a B.A. from Colby College.

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