HHS secretary defends surprise-billing arbitration process

HHS Secretary Xavier Becerra is defending CMS' proposed surprise-billing rule, bashed by several medical groups as an unfair gift to health insurers, according to Kaiser Health News.

The rule, released in two parts on Sept. 30 and July 2, represents the Biden administration's plan to enforce and implement the No Surprises Act, which shields patients against unexpected, out-of-network medical bills.

Under the surprise-billing rule, patients must be removed from the middle of the billing dispute. Instead, providers and insurers are required to work out how much the provider or hospital should be paid for the service. The process calls for providers and insurers to first enter a 30-day "open negotiation" period. If no agreement is reached, either party may initiate an independent dispute resolution process. 

Physician groups and medical associations have bashed the dispute resolution process, and several entities have filed lawsuits aiming to block the provision in the rule. The medical groups argue that the rule favors health insurers because it relies heavily on a benchmark largely determined by payers: the qualifying payment amount, or the median rate negotiated for similar services among in-network providers. The medical groups argue that this will let insurers drive reimbursement rates down and force more physicians out of network or even out of business. 

In defending the rule, Mr. Becerra said he's heard the concerns from the groups but the bottom line is protecting patients and lowering the cost of healthcare in the U.S. 

"Everyone has to give a little to get to a good place," Mr. Becerra told Kaiser Health News. "That sweet spot, I hope, is one where patients … are extracted from that food fight. And if there continues to be a food fight, the arbitration process will help settle it in a way that is efficient, but it also will lead to lower costs."

Mr. Becerra told Kaiser Health News that medical providers who charge exorbitant rates for out-of-network services will soon need to bear their share of the cost.

"I don't think when someone is overcharging, that it's going to hurt the overcharger to now have to [accept] a fair price," Mr. Becerra told Kaiser Health News. "Those who are overcharging either have to tighten their belt and do it better, or they don't last in the business."

Mr. Becerra added that while the administration chose a benchmark that physician and hospital groups don't like, the rule does specify that other factors should be considered by the entity overseeing the dispute process, including a provider's experience, the market and the complexity of a case. 

"What we simply did was set up a rule that says, 'Show the evidence,'" Mr. Becerra told Kaiser Health News. "It has to be relevant, material evidence. And let the best person win in that fight in arbitration."

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