Policy Making & Sausage

The Balance Billing Saga Continues in 2021: Part 1

By Ed R. Marasco, MPM, CMTE, EMT-P (Ret.)*

There is an old saying:

“The two things you never want to know about how they are made… public policy and sausage.”

Policy Making & Sausage - The Balance Billing Saga Continues in 2021: Part 1The ingredients and process can be very alarming. On the other hand, sausage is a great breakfast side and every now and then a policy can make sense. When public policy is successful it usually means that none of the interested parties are completely satisfied. And so, continues the saga of the balanced billing debate.

To get a full understanding of Balance and Surprise Medical Billing, please refer to the QMC blog series and podcasts in 2020.

On October 5, 2018, then President Trump signed the FAA Reauthorization Act of 2018 into law. Among many other provisions, the Act requires the Secretary of Transportation, in consultation with the Secretary of Health and Human Services, to establish an advisory committee to review options to:

    • Improve the disclosure of charges and fees for air medical services;
    • Better inform consumers of insurance options for such services;
    • Protect consumers from balance billing

The Air Ambulance Patient Billing (AAPB) Advisory Committee was empaneled, and the first session was held on January 15-16, 2020, at DOT headquarters and then COVID hit. Like so many aspects of our life in 2020 and 2021, the policy-making process required some flexibility and the desire to persevere. The work of the AAPB continued remotely with the activation of several Subcommittees comprised of AAPB members and invited industry experts. The Subcommittees worked throughout the remainder of 2020 and into the first quarter of 2021.

On May 27-28, 2021, the Subcommittees reported out their findings and recommendations to the full AAPB in plenary session. It was two LONG days of debate and the Committee members voted and reached agreement on nearly 20 recommendations concerning a variety of topics such as disclosure, data collection, independent dispute resolution, Medicare reimbursement study, and airline subscription programs. These recommendations as well as the views of the minority will be in the final report. Generally, the Chair prepares the report, coordinates with the committee members, then provides a final copy to the Designated Federal Officer (DFO). The DFO will assist in ensuring the report is transmitted to the Secretaries of DOT and HHS and Congress.

At the same time, this process was unfolding, other efforts to address the challenge were continuing and in December of 2020, Congress passed the No Surprises Act. The passage of the Act followed 3+ years of debate on the topic and in some respects, was a surprise itself. The key elements of the Act are:

    • Patient Protection
    • Balanced Billing Prohibitions
    • Dispute Resolution Framework
    • Payment Benchmarks
    • Independent Dispute Resolution (IDR) Provisions
    • Additional Consumer Protections
    • Advisory Committee for Air Ambulance Billing
    • Advisory Committee for Ground Ambulance Billing

The No Surprises Act circumvented 15 months of work by the AAPB on the air medical transport side of the issue, shifted the agencies with responsibility for the matter and established a timeline that is nearly impossible to accommodate. The shift from the Department of Transportation and Health & Human Services to a new group that includes the Department of Health & Human Services, as well as the Department of Labor, Department of the Treasury, and the GAO has complicated matters. This is particularly problematic because it left out the Department of Transportation, the agency with the responsibility of enforcing the Airline Deregulation Act.

The Act prohibits balanced billing as of January 1, 2022. There is almost no chance the key provisions of the Act that will prescribe the alternatives to balanced billing will be in place by January 1, 2022. Lastly, the regulatory process for the Act is condensed in a manner that will make it nearly impossible to have real dialogue about some of the key provisions such as the definition of the Median In-Network Rate and the rules of engagement around the IDR process.

There are real issues with the provider payment system in the United States and there is certainly a need to address the challenges of balanced billing. There has been widespread agreement on both points across all constituency groups in recent years. Unfortunately, the problem is complex and rooted in many years of evolution around our healthcare delivery system. At the same time, the sands are shifting and our focus in the healthcare delivery system has changed. In this case, there is a strong possibility that our sausage will be missing some key ingredients and will be undercooked.


*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement and consulting.

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