The leaders noted that the legislation requires the certified independent dispute resolution entity to consider:
- Median in-network rates
- Provider training and quality of outcomes
- Market share of parties
- Patient acuity or complexity of services
- Teaching status, case mix and scope of services if the provider is a facility
- Demonstrations of prior “good faith efforts” of negotiation with in-network rates
- Contract history between the two parties over the past four years
The letter said the interim final rule tells IDR entities to assume that the median in-network rate is the correct payment amount before examining other factors, creating a de facto benchmark rate, which is not how the process is laid out in the law as written.
“This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care — the exact opposite of the goal of the law,” the letter said. “It could also have a broad impact on reimbursement for in-network services, which could exacerbate existing health disparities and patient access issues in rural and urban underserved communities.”
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