Lobbying cranks up for another surprise billing fix
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Providers and insurers are so divided over the process for resolving surprise billing disputes that they can't even agree on the true size of the payouts. And the blame game is likely to continue into next year.
The big picture: The continued sparring four and a half years after a federal surprise billing law took effect is fueling fresh calls for another congressional "fix" to address a staggering backlog of cases and questions, like which disputed items and services can be lumped together.
- "There's been a change in the dynamic from even a few weeks ago," said Jack Hoadley, research professor emeritus at Georgetown's Health Policy Institute.
Driving the news: Insurers this summer have intensified calls to overhaul the independent dispute resolution process, saying it routinely awards providers big payouts that drive up the cost of care.
- Their arguments were boosted by a Wall Street Journal report on federal data that found the process awarded nearly $15 billion to providers last year — more than triple the total for 2024.
- The Trump administration issued a final rule in May aimed at streamlining arbitration, though some policy analysts predict the changes will only encourage more practices to take claims to arbitration. Insurers and employers both are pressing for more.
- "Action is needed to protect consumers and employers from indefensible and well-documented price gouging by some out-of-network providers and arbitration middlemen who flood the system with ineligible claims to extract exorbitant payments," said Mike Tuffin, president and CEO of the insurer trade group AHIP.
The other side: Providers say as much as $2.7 billion of the payouts the Wall Street Journal cited appear to be incorrect, and blame the flawed data for contributing to the perception that doctors are gaming the system.
- They point to insurers not engaging meaningfully in the negotiation process by refusing to pay more than 1 million disputed claims or offering rates of less than $1 for some services.
- "If we keep winning, why aren't insurers coming back to the table with a more reasonable offer?" said American College of Emergency Physicians President Tony Cirillo.
- The general idea was that if either side began to lose too often, it would ultimately change behavior. "And it hasn't changed," Cirillo said.
What we're watching: There's bipartisan traction for a legislative fix, possibly including penalties for submitting ineligible claims and prompt pay for providers — but it likely won't happen this year, TD Cowen analyst Molly Turco wrote in a recent note.
- The urgency could intensify if big insurers cite the arbitration process as a drag on their earnings. UnitedHealthcare criticized the process in its second-quarter earnings call, saying it's one of the reasons commercial insurance rates remain elevated.
- A federal appeals court on Tuesday partially sided with a Texas medical group's challenge to certain criteria used in the arbitration process, which could also increase pressure for Congress to weigh in.
