Helaine I. Fingold, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore office, was quoted in Modern Healthcare, in “‘Not So Optimistic’: Surprise Billing Arbitrations Cause Frustration,” by Maya Goldman. (Read the full version – subscription required.)

Following is an excerpt:

The surprise billing arbitration process has gotten off to a rocky start.

Insurers are accusing providers of submitting every possible claim, even when they know some cases are not eligible for mediation. Providers allege insurers are holding up the federal dispute process by delaying submissions of clear and complete information. The recently published final rule on the process from the Health and Human Services, Labor and Treasury departments likely will not resolve all these problems. ...

The No Surprises Act, which took effect Jan. 1, requires insurers and providers that fail to agree on rates for out-of-network care to engage in independent dispute resolutions overseen by arbiters. The Centers for Medicare and Medicaid Services unveiled the federal mediation portal in April.

Mediators decided just 1,200 out of 46,000 disputes submitted to the portal as of Aug. 11, according to the most recent federal data. CMS received “substantially more” cases to review than initially expected, the agency reported this month. Three of the 11 independent dispute resolution entities are no longer accepting new cases, according to CMS. ...

Time spent determining how many of these cases qualify for federal arbitration has been the primary cause of delays, CMS reported in a notice this month. Insurers and providers that did not initiate disputes have challenged the eligibility of mediation for more than 21,000 cases, and arbiters tossed out 7,000 more. ...

Another factor that will increase costs: Policymakers issued guidance alongside the final rule that clarifies that insurers cannot use “ghost rates” to calculate the median in-network rate for specialty services. ...

But these lawsuits may not stand now that the rule has been finalized. “I don't think there's anything in the law that will support giving primary weight to the alternative information coming in,” said Helaine Fingold, a lawyer at Epstein Becker & Green who represents insurers and providers.

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