Health Plan Weekly

Biden Administration Targets Surprise Billing ‘Loophole,’ but Regs May Not Fix Problem

  • Jul 14
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    Jul 14, 2023

    The Biden administration released new regulatory guidance meant to block a loophole in the No Surprises Act (NSA) that payers and providers had exploited to send large bills to some patients. However, an attorney tells AIS Health, a division of MMIT, that providers and payers will find ways to work around NSA provisions.

    The No Surprises Act, a 2021 law, banned balance or “surprise” billing in most cases. Balance billing occurs when an out-of-network provider will not accept the payment rate offered by a patient’s insurance plan. The law also set up the Independent Dispute Resolution (IDR) arbitration process, which is meant to resolve bills that insurers and providers are unable to agree on themselves. During IDR, providers submit unresolved bills to an HHS-approved arbitrator, who then selects an amount submitted by either the payer or the provider using criteria laid out by HHS. The plan is then required to pay that amount to the provider.

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    • Peter Johnson

    Peter has worked as a journalist since 2011 and has covered health care since 2020. At AIS Health, Peter covers trends in finance, business and policy that affect the health insurance and pharma sectors. For Health Plan Weekly, he covers all aspects of the U.S. health insurance sector, including employer-sponsored insurance, Medicaid managed care, Medicare Advantage and the Affordable Care Act individual marketplaces. In Radar on Drug Benefits, Peter covers the operations of (and conflicts between) pharmacy benefit managers and pharmaceutical manufacturers, with a particular focus on pricing dynamics and market access. Before joining AIS Health, Peter covered transportation, public safety and local government for various outlets in Seattle, his hometown and current place of residence. He graduated with a B.A. from Colby College.

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Executive Editor, AIS Health, and Managing Editor, Radar on Medicare Advantage

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Reporter, Radar on Medicare Advantage and Spotlight on Market Access

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