WASHINGTON, D.C. – (January 31, 2022) – No one should face a surprise medical bill that could lead to financial ruin. In its amicus brief filed today in the U.S. District Court for the District of Columbia in American Medical Association v. U.S. Department of Health and Human Services (HHS), AHIP argues in support of HHS’ legal arguments for its rules for implementing the No Surprises Act, and that HHS’ cross-motion for summary judgment should be granted. Here are the highlights:
Health Insurance Providers Protect Patients from Surprise Medical Bills
“AHIP’s members strive to reach agreements with health care providers to offer consumers affordable networks that provide them with choices in the delivery of quality medical care. When unable to secure network agreements before treatment is rendered, health insurance providers have long worked to negotiate out-of-network payments to prevent surprise medical bills and reduce costs for patients. This approach was no solution to the growing problem of providers remaining out-of-network when, due to the nature of the provider’s medical specialty, patients are unable to choose a provider in advance. Invariably, the result was that such out-of-network providers were paid well above typical market rates, even for their specialty peers, and consumers faced excessive costs—including to the point of bankruptcy—when providers demanded to be paid the balance of unreasonable billed charges.”
HHS’ Rules Are Appropriate and Will Protect Americans from Higher Health Care Costs
“AHIP strongly supports Congress’s decision in the No Surprises Act to fix the market dysfunction that saddled patients with exorbitant medical bills for services they had no opportunity to turn down. AHIP also agrees with Defendants’ legal arguments that the Act’s fix hinges on anchoring disputed out-of-network rates to the ‘qualifying payment amount’ (QPA), absent credible information otherwise. The QPA reflects competitive, fair market rates, and Plaintiffs’ unbounded alternatives would create the very problems the Act aims to remedy.”
HHS Needed to Act Swiftly for Timely Operationalization of the No Surprises Act
“To allow for an operational IDR process by January 1, 2022, health plans needed clear guidance. Requiring the IDR process to begin with the QPA—rather than an open-ended multi- factor weighing with no structure—provided much-needed certainty. Finalizing the rules allowed health insurance providers to finalize benefit designs; obtain regulatory approvals; set up staffing, systems, and vendor contracts to handle claims and disputes; and, when acting as third-party administrators on behalf of employers that pay for their employees’ health care services, set up systems to accurately predict those employers’ anticipated costs, administer their claims, and handle any disputes.”
Before the No Surprises Act, Certain Providers Often Avoided Joining Networks
“For services where patients are unable to choose an in-network provider in advance, providers lack the same incentives to join networks, resulting in lower network participation rates for certain providers, like those that provide emergency care, or are assigned by the hospital without patient direction, such as anesthesiologists and pathologists.”
Health Insurance Providers Have Every Incentive to Build Robust Networks
“Health insurance providers…have every incentive to move more providers into networks. If network agreements cannot be reached based on reasonable market rates, however, then structured decision-making—where competitive, negotiated rates like the QPA (which itself reflects a range of market rates) provide an anchor for resolving disputes—protects consumers from premium increases tied to skyrocketing out-of-network charges by ensuring more predictable out-of-network payments.”
AHIP Supports HHS’ Cross-Motion for Summary Judgment
“The Court should deny Plaintiffs’ motion for summary judgment and grant Defendants’ cross-motion for summary judgment.”
About AHIP
AHIP is the national association whose members provide health care coverage, services, and solutions to hundreds of millions of Americans every day. We are committed to market-based solutions and public-private partnerships that make health care better and coverage more affordable and accessible for everyone. Visit www.ahip.org to learn how working together, we are Guiding Greater Health.