Physicians Advocacy Institute (PAI), American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS), banned together with 16 state medical associations and seven national medical societies to officially support the American Medical Association (AMA) and American Hospital Association’s (AHA) lawsuit filed in December against the Department of Health and Human Services. The coalition filed an amicus curiae brief last week in opposition of the No Surprises Act (NSA) dispute resolution guidelines.
Of note, the coalition’s amicus brief strongly supports the patient protections in the NSA, as does the original lawsuit. Like the lawsuit, the amicus brief opposes how the current interpretation relies on insurers’ self-determined median in-network billing rate, rather than on the numerous factors originally called for with the law, to resolve billing disputes. The amicus brief cites not accounting for the several factors the law originally calls for gives insurers an unfair upper hand.
The No Surprises Act (NSA) took effect on January 1 and puts restrictions on the amount patients can pay out-of-pocket for out-of-network services and providers. For example, if a patient needed emergency services in the ER, the provider available may not be in network or the lab running tests ordered in the ER may not fall within the patient’s insurance network. As such, the NSA endeavored to protect patients from excessive bills by requiring insurance to only bill patients for the median in-network billing rate using several factors, even if out-of-network.
However, several groups have taken issue with a rule federal regulators issued regarding guidelines for determining the in-network rate to be applied to the out-of-network services. In particular, the lawsuit filed in December and the supporting amicus brief specifically raised issue with how the rule allows insurers to use self-determined median in-network billing rates when disputes arise. Proponents of the lawsuit argue that the rule unfairly gives insurers influence on resolving disputes by allowing them to focus on this one item, rather than the several holistic factors called for in the original bill.
Specifically, the lawsuit and amicus brief propose that the guidelines will unfairly lower the amounts providers ultimately receive.
“Physicians have an obligation to reinforce for the court just how far federal regulators walked away from the No Surprises Act’s balanced approach to resolving payment disputes and explain how bypassing the law will unfairly empower insurers at the expense of patients and their physicians,” said Dustin Corcoran, president of PAI and chief executive officer of the California Medical Association in a news release.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
The following groups backed the amicus brief: American Association of Neurological Surgeons, American Association of Orthopaedic Surgeons, American Society of Hematology, California Medical Association, Michigan State Medical Society, Texas Medical Association, and the Washington State Medical Association, among others.
“This deeply flawed regulation represents an approach Congress dismissed because it recognized that failure to consider multiple factors before deciding a payment dispute would make it harder and more costly for patients to access physicians, particularly for specialty care,” said Dr. John K. Ratliff, a practicing neurosurgeon at Stanford University and chair of the AANS/CNS Washington Committee in a press release.
The upcoming months will show how insurers resolve disputes in practice and how those decisions ultimately impact providers’ bottom line.
Photo: Gearstd, Getty Images
