American medical and hospital associations file suit over surprise billing provision opposed by radiologists
The country’s largest lobbying groups representing physicians and hospitals have filed suit over a controversial surprise-billing provision opposed by radiologists and other specialists.
Both the American Medical Association (AMA) and American Hospital Association (AHA) are taking the Biden administration to court over recent rulemaking aimed at banning unexpected medical bills. The two said they support the effort but believe the departments of Health and Human Services, Treasury and Labor are failing to honor Congress’ original intent in implementing the law.
As proposed in October, the AMA and AHA argue the law will tip scales in favor of health insurers and reduce patients’ access to care by discouraging “meaningful” contract negotiations.
“Congress established important patient protections against unanticipated medical bills in the No Surprises Act, and physicians were a critical part of the legislative solution,” AMA President Gerald Harmon, MD, said in a statement. “But if regulators don’t follow the letter of the law, patient access to care could be jeopardized as ongoing health plan manipulation creates an unsustainable situation for physicians. Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between healthcare providers and insurance companies.”
Attorneys filed the complaint Thursday, Dec. 9, in the U.S. District Court for the District of Columbia. Fellow plaintiffs in the suit include Renown Health system in Nevada, UMass Memorial Health in Massachusetts, and two North Carolina physicians. Providers have centered their concerns around the latter, after the local Blue Cross Blue Shield became the first insurer using the legislation to demand docs accept pay cuts.
The No Surprises Act would deploy a baseball-style independent arbitrator to settle payer-provider disputes over out-of-network services. Docs and hospitals are concerned about use of the “qualifying payment amount” — essentially the insurer’s median contracted rate for the same or similar service in the geographic area — as the key negotiating point. Providers want other factors considered such as quality of outcomes, market share, patient acuity, scope of services at the facility, and prior contract history between the two parties.
AMA and AHA’s action comes after the Texas Medical Association filed suit in November for the same reasons. The American College of Radiology also opposes the provision and has said it is considering legal action, too. ACR recently submitted comments to the Centers for Medicare & Medicaid Services, urging the feds to fix the interim final rule.
“If the regulations are not changed, the result may be a downward trend of in-network payment rates and/or physicians being dropped from insurer networks, as already seen by insurers in North Carolina,” ACR said in a Dec. 9 news update.
Providers have policymakers on their side, with 150 members of Congress pressuring the administration to modify the No Surprises Act to match their intent when passing the policy in December 2020. HHS Secretary Xavier Becerra — named in the AMA lawsuit — has defended the final rule, urging providers to “tighten their belt.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.