AHIP Backs HHS In Surprise Billing Suit, Pushes Back Against Provider Claims

Dive Brief:

  • * As litigation surrounding the ban on surprise billing heats up, the insurance lobby has filed a legal brief in support of the government’s implementation of the bill Congress passed in 2020 to outlaw the controversial practice, which leaves patients stuck in the middle of payment disputes between payers and providers.
  • * Siding with the HHS, AHIP argued the administration got it right when constructing the methodology behind the ban and, more specifically, how disputes around payments will be resolved through the arbitration process, according to the brief AHIP filed Tuesday in federal court in Texas.
  • * Relying on the qualifying payment amount, or median in-network rate, helps center the payment dispute, creating a starting point for when payers and providers may need to turn to a third-party arbiter. It also creates predictability and ultimately lowers costs, AHIP said.

Dive Insight:

The lawsuit in Texas is just one of four legal challenges to the federal ban on surprise billing, Katie Keith, who is tracking these suits at Georgetown University’s Center on Health Insurance Reforms, said in a briefing on Jan. 6.

These challenges all target a narrow piece of the law, the vehicle for how payment disputes are resolved, through what is known as independent dispute resolution.

The independent dispute resolution process is a key piece of the law. It’s the last step in the process to resolve a payment dispute between payers and providers. Under the law, IDR entails turning to a third party, in this case an arbiter, to settle the payment disagreement.

But how CMS chose to implement this IDR process has spurred debate, resulting in the multiple legal challenges.

CMS said that when payers and providers enter into the IDR process, the arbiter “must begin” with the presumption that the qualifying payment amount is the appropriate out-of-network payment.

Relying on the QPA in this way has generated intense pushback from providers who say it’s tipping the scales in the favor of insurance companies.

But AHIP, which lobbies on behalf of insurers, objects to that assertion, according to its brief filed Tuesday in a case brought by the Texas Medical Association and Texas physician Adam Corley against HHS.

“The QPA reflects competitive, fair market rates, and Plaintiffs’ unbounded alternatives would create the very problems the Act aims to remedy,” according to the brief.

AHIP is arguing that the QPA is essentially a starting point for how arbiters should orient themselves when considering what a physician should be paid for an out-of-network service. Healthcare prices in the U.S. are notoriously opaque and the price of a single procedure can vary widely.

The QPA is meant to reflect the median rate that payers and providers contractually agree to for the same service, in the same area.

When using this as a starting point, it creates predictability and will ultimately lower costs, AHIP argued.

Lobbying groups for hospitals and doctors also are challenging the use of the QPA in federal court. Similarly, the providers say it “places a heavy thumb on the scale” of the dispute resolution process that will unfairly benefit insurers.

That case is playing out in the Washington, D.C., district court and the judge has recently laid out a timeline of filing deadlines to keep the case moving forward as surprise bills disputes will need resolutions in the coming months.


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