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Neurosurgery Backs AMA Lawsuit Over Surprise Medical Billing Rules

On Dec. 9, the American Medical Association (AMA) and American Hospital Association (AHA) filed suit against the Biden Administration in an effort to stop part of the surprise billing regulations from going into effect in January. The interim final rule (IFR) implementing the No Surprises Act requires arbitrators to primarily use the “qualifying payment amount” (QPA), which is based on median contract rates, in deciding billing disputes over out-of-network charges. However, as pointed out in the lawsuit, the statute clearly states that the arbitrator “shall” consider many factors, not just the QPA, in determining fair payments. These factors include the experience and level of training of the doctor, the complexity of the service and prior contract history between the plan and provider.

In November, 152 bipartisan members of Congress sent a letter (which the AANS and the CNS supported) to the administration regarding the dispute resolution process, saying that directing the arbitrator to “begin with the assumption that the median in-network rate is the appropriate payment amount” creates a “de-facto benchmark rate” that could hurt providers and ultimately health care access. National surgical organizations, including the AANS and CNS, agree with this interpretation of the law. In their comment letter responding to the IFR, the groups called on the administration to revise the new rules before they take effect on Jan. 1. A de facto median in-network payment rate will drive down reimbursement for both out-of-network and in-network care and will likely exacerbate the problem of narrow provider networks. Anticipating the new rules, health plans are now demanding lower contract rates. For example, Blue Cross Blue Shield of North Carolina has begun sending letters threatening contract termination unless the physicians immediately agree to payment reductions ranging from 10 to over 30%

The AANS and CNS will be leading an amicus brief effort supporting the AMA/AHA lawsuit. Other state medical and national specialty societies will join this initiative.