Medical Billing Services For Small Practices | Texas Medical Association Sue Feds Over Idr For Surprise Billing

The Association claims that officials from the Federal government are not providing “clear direction” on how to establish the process of independent dispute resolution within the law of surprise billing. The Texas Medical Association is taking action against a proposed regulation to be implemented under the No Surprises Act, federal law on surprise billing that goes into effect on January 1st.

The Association recently announced that it had filed an action against a number of federal agencies, including HHS, who jointly issued this regulation in September. The lawsuit, filed on the 28th, claims that the September regulations “undermine Congress’s design” of the independent dispute resolution (IDR) procedure in the No Surprises Act.

The No Surprises Act was passed in December 2020 in order to prevent the practice of surprise billing. It usually occurs when patients are presented with an unexpected bill following receiving care from an outside-network provider in-network. Congress also included within the Act an IDR process to address the issue of payments for these medical bills. Patients are no longer required to pay the full amount in all situations.

  • What the No Surprises Act Means for Providers
  • What Revenue Cycle Can Do to Prepare for Surprise Billing Compliance

Hospitals Offer Suggestions for Surprise Billing Law Implementation

In the IDR process, both the providers and payers have to submit a rate proposal in writing to an IDR entity. The IDR entity then chooses one of the rates as the final, binding reimbursement out-of-network fee for the dispute charges depending on a range of factors like the qualifying amount (QPA) or the average contracted rate paid by the payer for the service being sought, as well as the level of acuity of the person who was treated, as well as the degree of experience, training, and the caliber of the facility or provider who provided the services. For Health Care Fraud Prevention and medical billing services, go to the website.

The Texas Medical Association explains in the suit that the No Surprises Act makes it clear that the IDR entity has the ability to take into account all these elements as well as other factors, and that any factor is not privileged over another. However, the regulation of September stipulates that an IDR entity is required to take into account the QPA over other elements, as per the lawsuit.

“Nowhere did Congress specify that the QPA, or any other factor for that matter, should be given primacy over the other enumerated factors,” says the suit. The incorrect rules “will skew IDR results in favor of payers and undermine [physicians’] ability to obtain adequate compensation for their services,” the lawsuit continues.

Also, the federal government prohibited the ability of providers to voice their opposition to the IDR process by not allowing the notice and comment period after the publication of the IDR regulation, plaintiffs contend.

The Association is concerned that the IDR process, as detailed in the regulation of September, could encourage payers to cut their provider networks and lower the reimbursement rates for doctors in order to reimburse providers outside of the network less for disputable charges in this new regulation.

The narrow provider networks are already a problem, according to a new analysis by the American Medical Association (AMA), which also expressed its displeasure over the September regulations. The study found that nearly three-quarters of metropolitan statistical areas are heavily concentrated in the hands of payers. More than nine out of 10 markets also had a player that held a minimum of 30 percent of the market share. About half of the markets had an insurer with a 50 percent market share.

As the AMA explained, the highly concentrated market for health insurance hinders competition and leaves patients with more expensive premiums and smaller provider networks. This is a major reason behind unexpected medical bills. The suit brought by the Texas Medical Association seeks to remove the provisions contained in the regulation of September.

“We are disappointed the Biden administration ignored congressional intent and essentially set up the arbitration system to operate like a casino, with health insurers playing the role of the house,” Linda Villarreal, MD, president of the Texas Medical Association, said in the statement. Everyone is aware that the house always wins. In the current system, doctors, patients, and even our country suffer. “