ERISA Industry Committee disappointed with final surprise medical billing regulations

The final surprise medical billing regulations issued last week fall well short of the intended goal, according to the ERISA Industry Committee (ERIC).

“Instead of taking steps to lower health care costs — especially in these inflationary times — the federal departments watered down the surprise medical billing requirements that dictate how much an employer-sponsored self-insured health plan is required to pay when emergency services are furnished by an out-of-network provider and when an out-of-network provider furnishes services at an in-network medical facility,” the industry association says in a news release.

Late last week, the U.S. Departments of Labor; Health and Human Services; and the Treasury issued final rules concerning standards related to the arbitration process implementing the act, a bipartisan law to protect consumers against surprise medical bills.

“Today’s final rules will make certain medical claims payment processes more transparent for providers and clarify the process for providers and health insurance companies to resolve their disputes,” according to a statement from the Labor Department. “The increased transparency required under these final rules will help providers, facilities and air ambulance providers engage in more meaningful open negotiations with plans and issuers, and will help inform the offers they submit to certified independent entities to resolve claim disputes.”

The rules also finalize some aspects of the arbitration process afforded by the No Surprises Act. Parties or providers (including air ambulance providers), facilities, plans and issuers may use an arbitration process known as the Independent Dispute Resolution (IDR) process to determine the total payment amount for out-of-network health care services for which the act prohibits surprise billing. The final rules include guidance for certified IDR entities on how to make payment determinations and requires them to provide additional information and rationale in their written decisions.

The final rules address certain provisions of the July and October 2021 interim final rules that are relevant to the operation of the federal IDR process and revise certain provisions in light of two recent federal court decisions in challenges filed by the Texas Medical Association and LifeNet Inc.

Related: Survey: No Surprises Act prevented more than 2 million unexpected medical bills

According to ERIC, however, self-insured employer plan sponsors will continue to pay inflated amounts to out-of-network providers that charge unreasonable fees. This not only will increase costs for the plan sponsor but also for employees and their families covered under self-insured health plans.

“Unfortunately, the final rule falls short of lowering health care costs for employer plan sponsors and ultimately, patients,” ERIC CEO Annette Guarisco Fildes says. “Instead of adhering to Congress’s original intent, the administration backtracked on limiting out-of-network payments to reasonable market-driven rates. The administration’s actions will not lower health care costs. To the contrary, plan sponsors and the employees to whom they provide health coverage will continue to be forced to line the pockets of medical providers that choose to remain out-of-network.”