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The ERISA Industry Committee wants the Internal Revenue Service to help revamp the current No Surprises Act medical bill dispute resolution process, to keep the process from driving up plan costs instead of simply protecting patients from surprise bills.
James Gelfand, the president of ERIC, told the IRS that it should repeal the regulations that now govern the NSA process.
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The IRS works with the U.S. Labor Department's Employee Benefits Security Administration and the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services to develop many major federal health insurance and health benefits regulations, including the NSA regulations.
Since the existing NSA process started up, providers have flooded independent dispute resolution systems with appeals, and "providers have prevailed 80% of the time," Gelfand told the IRS in a letter about what the IRS should do next.
The rates the out-of-network providers get when they dispute the original allowed amounts are often much higher than the "qualifying payment amounts," or the rates the providers would get if they were caring for the same plans' patients on an in-network basis, Gelfand wrote.
Provider manipulation of the NSA dispute resolution system and waves of provider lawsuits about qualifying-payment-amount calculations have "undermined the core purpose of the NSA — to protect patients from overpaying for access to their care," Gelfand added.
He said the solution is for the IRS and other federal agencies to repeal and revise the current billing dispute resolution process regulations, to provide clearer guidance for both health care providers and payers.
The letter: ERIC is a group for employers with self-insured health plans and other plans that come under the regulatory framework created by the federal Employee Retirement Income Security Act of 1974.
Gelfand sent his letter in response to the latest IRS request for ideas about what it should put on its to-do list.
The surprise bill fight: Employers and benefits brokers have been working for decades to keep insured patients who follow health plan rules from getting big, unexpected medical bills.
Congress put measures intended to prevent some types of unexpected bills in the NSA, which was part of the Consolidated Appropriations Act of 2021.
The provisions are supposed to protect patients from balance billing when they get care from out-of-network providers at in-network hospitals and when they receive emergency hospital care.
ERIC was a strong supporter of the thinking behind the NSA, but it and other benefits groups said the regulations governing billing disputes between providers and plans were too favorable toward the providers.
Many health care providers have used MultiPlan, a claim administrator, to handle the out-of-network claims.
Providers have alleged in big waves of lawsuits involving MultiPlan that the plans used MultiPlan to share information in a way that depressed reimbursement rates for out-of-network care.
Related: MultiPlan, UnitedHealthcare provider antitrust lawsuit dismissed
MultiPlan and the plans said they were using public information to defend themselves against very high claims.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
