Burdens, Potential Harms Cited in Price Transparency Rules

AAFP Calls for Important Refinements to Regulations

Dec. 7, 2022, 9:17 a.m. News Staff — New administrative complexity emerging from policy meant to limit surprise billing will overwhelm primary care practices, worsen staffing shortages and undermine patient care unless regulatory adjustments are made, the Academy warned regulators. The AAFP’s guidance called for enforcement exemptions for primary care practices and other refinements.

“Congress did not intend for the No Surprises Act to impose burdensome regulatory requirements on primary care practices, who typically are in-network, provide high-value care to patients who have chosen to see them and are already overburdened with administrative tasks,” the AAFP told HHS. The letter also went to the departments of treasury and labor, which, respectively, regulate federal employee health plans and commercial insurance plans.

The Academy was responding to a request for information titled “Advanced Explanation of Benefits and Good Faith Estimate for Covered Individuals,” published Sept. 16 in the Federal Register. The RFI sought stakeholder feedback ahead of implementing — after a delay the Academy supported — the “Advanced Explanation of Benefits” requirements in the No Surprises Act, enacted as part of last year’s Consolidated Appropriations Act. The legislation, which went into effect Jan. 1, solidifies a number of patient protections for which the AAFP had advocated.

It also introduces an array of new reporting and information-sharing requirements to primary care practices that have already been buffeted by the COVID-19 public health emergency — requirements, the AAFP reminded regulators, rooted in the law’s focus “on unanticipated medical bills from air ambulance providers, hospitals, emergency departments and out-of-network clinicians and facilities” rather than on family physicians.

Under the AEOB and good-faith elements of the No Surprises Act, all patients must be asked whether they are enrolled in an individual or a group health plan and then, for a patient so enrolled, the insurer must get an estimate of expected charges. After receiving the estimate, plans must make available to the patient an explanation of benefits that includes whether the clinician or facility is in-network, what portion of charges the plan will pay and whether there are cost-sharing requirements.

The law also requires clinicians and facilities to make good-faith estimates available directly to uninsured patients or those paying completely out-of-pocket before care is given. The good-faith estimate regulations are in effect; the AAFP has repeatedly shared concerns about the burdens of providing estimates to this typically smaller patient population.

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“The AAFP is deeply concerned that, once implemented, the AEOB requirements will add a much greater level of administrative burden and further diminish staff time devoted to caring for patients,” the November letter warned. “In addition to being inconsistent with the spirit of the No Surprises Act, AEOB requirements for primary care are likely to lead to confusion and frustration for patients.

“Before seeing the patient, it will be incredibly challenging for the practice to make a reasonable determination about the patient’s condition or the resulting tests, treatments, referrals or other services that may be needed,” the Academy added. “Requiring practices to generate the GFE will force them to guess, which will result in an inaccurate or irrelevant AEOB being sent to the patient, undermining the overall goal of the AEOB requirements.”

Citing the most recent Medical Group Management Association report on regulatory burden, in which 90% of respondents expressed concern about complexities stemming from AEOB requirements, the AAFP called on regulators to

exempt from the rule preventive services that individual, group and self-insured health plans are required to cover without cost-sharing under the Patient Protection and Affordable Care Act;
provide an exception when the patient chooses to forgo receiving an AEOB;
let primary care practices issue one GFE annually (resulting in a single AEOB for patients) “for ongoing, longitudinal primary care services, including those related to the monitoring and treatment of chronic conditions” as well as for acute conditions or other care requiring recurring appointments with a primary care physician;
not impose deadlines for practices to generate GFEs and send them to insurers;
require health insurers to send a patient’s AEOB to the physician practice that submitted the GFE information for that AEOB; and
allow primary care practices to provide an abbreviated GFE/AEOB for new patients or when relevant diagnostic and procedure codes cannot reasonably be determined.

Such abbreviated GFE/AEOBs, the letter added, would include a range of expected charges but would not include diagnostic or procedure codes. “This will lessen the potential for GFE requirements to cause care delays, address the unnecessary and inappropriate burden on patients and administrative staff and result in a more positive experience for patients,” the Academy wrote.

The AAFP also pointed out technical challenges it said regulators should address before implementing the AEOB requirements in any health care setting, including

the lack of an existing standard to efficiently transmit GFE and AEOB information among practices, payers and patients;
fast health care interoperability resources–based application programming interfaces that, the letter cautioned, are “insufficiently mature for the real-time exchange of health care data”; and
unclear regulations governing how insurers separate data systems and teams processing GFE and AEOB data from other insurer functions.

The letter called for a pause on AEOB requirements until fast health care interoperability resource standards are “developed, thoroughly tested in real-world settings and ready for use by physician practices.”

“Action is needed to ensure that health insurers will use the GFE/AEOB data they receive in a responsible manner,” the Academy added. “The AAFP strongly encourages the departments to explore other safeguards to protect patients’ health information and the patient-physician relationship.”

HHS recently said it will delay enforcement of some GFE provisions that were slated to begin on Jan. 1, 2023, "pending future rulemaking." The AAFP continues to advocate for further action.