Friday, December 10, 2021

AHA and AMA Sue Government over Surprise Billing Law

Last December's surprise billing law goes into effect in January 2022, and HHS has been rolling out regulations and guidance documents.  Generally, it caps payments to out of network providers at the median of a payer's in-network rates.  360Dx had an August subscription article on implications for labs (here).

New news.  AMA and AHA file a lawsuit against HHS regarding misguided implementation of the law.

  • Press release here.
  • AMA says No Surprises Act bad, here.
  • Kaiser Health News here.
  • Fierce Healthcare here.
  • Healthcare Finance News here.
One of my takes on this is that it changes the "game theory" of contracting.  Let's say a health plan contracts with one hospital at $100, another at $125, another at $150.  Health plan could drop the top two hospitals from network, and contract with only the $100 hospital.  Then the second and third hospital will get paid by law at the $100 median in network rate, without bothering to contract with them.   Just an example.  The actual rules are complex.  Labs have faced contracting network strategy games for years - do you want to bill $100 out of network, hoping to get paid 50% or $50, but maybe zero, or do you want to contract in network for $45 you can count on reliably?  

See a mid-November article at NPR, "Doctors mad at surprise billing rules," with strong comment from Secr. Becerra that the law is good and will stop over-billing by certain providers.

Surprise Billing Law

Telemedicine surprise can get unexpectedly caught in the Surprise Billing Law.   What if you're an out of network telemedicine provider and charge $100 for 30 minutes, but the payer's in-network rate is $15 for 30 minutes?   See an article at HealthcareFinance here.  See an earlier note from McDermott here.