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

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.