Premier Comments on Surprise Billing Interim Final Rule

Premier submitted comments in response to the interim final rule (IRF) implementing consumer protections against unexpected medical bills in the No Surprises Act, which was incorporated into the Consolidated Appropriations Act of 2021. The IFR prohibits balance billing and out-of-network cost sharing for patients seeking emergency care or unknowingly receiving care from out-of-network providers at in-network facilities. While Premier generally supports the provisions of the IFR that are designed to ensure patients are held financially harmless when they unknowingly receive care from an out-of-network provider—particularly during a medical emergency—there are several key areas where the administration could improve the regulations and their implementation. Premier recommends that the administration:

• Provide state-by-state guidance for payers, providers and hospitals navigating the complex landscape of state and federal balance billing laws

• Revise qualifying payment amount (QPA) methodology and required disclosures
  • Remove value-based arrangements from QPA calculations to avoid artificially lowing the median rate
  • Give preference to existing value-based arrangements, rather than the QPA, when resolving reimbursement disputes
  • Calculate separate QPAs for different types of hospital-based emergency departments to account for payment and population differences that safety net and teaching hospitals face
  • Include single case agreement rates in median contracted rate calculations for the QPA
  • Require plans or issuers to disclose to providers all rates that factor into QPA calculations, along with disclosing whether such rates include value-based payment adjustments, and to respond to provider requests for additional information within 10 days

• Streamline patient communication
  • Require that payers, rather than providers, communicate information about in-network provider options to patients
  • Allow additional flexibility in required timelines for providing notice and consent, particularly for patients seeking ongoing care from out-of-network providers

• Reduce burden and complexity for third party administrators (TPAs)
  • Allow TPAs to calculate the QPA using contracted rates for all self-insured group health plans they administer for a given item or service, provider or facility type, and geographic region
  • Allow TPAs to use their own databases as a source of information about contracted rates in cases of insufficient information
  • Require that any third-party databases used in QPA calculations be equally accessible to providers, and allow providers to challenge questionable data sources