Statement: Govt. releases final rules for No Surprises Act

WASHINGTON — The Departments of Labor, Treasury and Health and Human Services issued final rules Friday about the provisions of the No Surprises Act related to settling payment disputes between out-of-network providers and insurers. The new version clarifies mechanisms that would assure cost savings for insured Americans. The Act, which went into effect on January 1, protects insured Americans from surprise medical bills and establishes payment guidelines for arbitrators to use when deciding disputes between out-of-network providers and insurers. The arbitration system, originally defined in the September 2021 interim final rules, has been the target of at least eight lawsuits brought by medical providers. Arbitration rules are key to whether the Act can hold down costs for insured Americans. In a case brought by the Texas Medical Association, a district court in Texas invalidated some parts of arbitration guidelines established in the interim final rule. 

After an initial review of the final rules, U.S. PIRG’s health care campaigns director Patricia Kelmar, issued the following statement: 

“The No Surprises Act was intended to end the common billing practice of certain providers and specialties who used their out-of-network status to raise prices and increase their profits. Those expensive surprise charges not only burden patients who are billed hundreds or thousands of dollars, but also they increase the overall cost of health insurance.  

“The law designed the arbitration process to hold down costs by creating guard rails to establish reasonable, predictable provider payments and prevent lottery-sized awards. Based on my initial review, the final rules emphasize that payments should reflect the value of the care provided, starting with the median in-network rate for that service in that geographical area. Arbitrators can consider other factors to award a higher payment to the provider, but only credible factors that haven’t already been accounted for in billing codes. Because the rules also require arbitrators to provide written explanations about their decisions, the government should closely monitor these explanations to make sure the process results in fair prices. The ultimate goal is to encourage providers to negotiate with insurers and join insurance networks. Pricing without limits drives up costs for patients and for all those with insurance.”