PBGH Strongly Supports the No Surprises Act Interim Final Rule: A Big Win for Consumers and Employers

On Sept. 30, the Departments of Health and Human Services, Labor and Treasury, released an interim final rule (IFR) implementing the No Surprises Act, which was enacted in December 2020. Starting on January 1, 2022, patients will no longer face the prospect of “surprise bills,” which subject patients to a balance bill for seeing an out-of-network provider through no fault of their own. In its rules implementing the law, the three departments also defined the process for how health care providers and health plans will settle remaining out-of-network claims.

PBGH strongly supports the interim final rule promulgated by the agencies.

In establishing the Independent Dispute Resolution (IDR) process, the three agencies adopted the recommendations of PBGH and other health care purchaser and consumer organizations in placing primacy of an arbitrator’s decision on the qualifying payment amount (QPA). The law defines the QPA as the median contracted (in-network) rate for the service in the geographic area. In the regulation, the agencies provided strong guidance to arbitrators by making it clear that they should choose the offer that is closest to the QPA “unless the certified IDR entity determines that credible information submitted by either party clearly demonstrates that the QPA is materially different from the appropriate out-of-network rate.

“This clarity and commitment to basing the arbitration around the local market rate reduces the incentive of health care providers to go to arbitration,” said Shawn Gremminger, PBGH Director of Health Policy. “The net result will be lower administrative costs and lower prices for employers, their employees and their families.”