By: Rebecca Herzberg
Volume IX – Issue I – Fall 2023
Introduction: Healthcare in the United States
Accessing affordable and quality health care has been an ongoing source of frustration for Americans for decades. Despite the constant development of new medical technologies, treatments, and drugs, the system through which Americans access their care has become increasingly confusing. Health insurance companies along with hospitals and providers have turned health into a business market no different from retail or food markets. The lack of a singular public insurance option facilitated by the government, like many other countries of similar socioeconomic status such as the United Kingdom and Canada, has allowed private insurers along with health systems to charge patients as they see fit. This freedom has resulted in Americans facing payments significantly higher than their counterparts in other countries due to the lack of coordination among these various players in the health industry. Relatedly, there are many variations of insurance and insurance-related issues Americans find themselves experiencing due to the for-profit business approach of the United States healthcare system.
Private insurance companies have devised systems to reduce their spending on providers and hospitals through creating networks of physicians who agree to their prices: preferred provider organizations (PPO). If a physician finds themselves in a PPO, they may receive lower payments than they would like, but they can be sure that the insurer will direct their enrollees to their practice. Conversely, if a physician is not in a PPO, they may struggle to attract patients due to insurance companies’ unwillingness to pay their prices. However, these out-of-network physicians can command higher prices which may be a better trade-off for them. Moreover, many highly nuanced scenarios occur within healthcare systems that patients are rarely informed about. For instance, a hospital may be within an insurance company's network, but that hospital could employ physicians who are out-of-network. This subtle distinction is generally not explained to patients and they often do not become aware of this significant cost-impacting information until after the fact. Relatedly, another nuanced scenario that is highly probable is that the primary physician a patient is interacting with is in-network, but some of the other physicians who treat them, under the direction of that primary provider, are actually out-of-network. These out-of-network providers may command a significantly higher cost, unbeknownst to that patient. In addition to not knowing the network status of their physicians, it was once not required that patients be informed of their approximate medical costs upfront.
While this issue might be avoided in non-emergency care settings, it is almost completely unavoidable when it comes to emergency care. When a person is picked up by an ambulance, they are generally taken to the closest appropriate hospital since the chief priority is ensuring the patient receives sufficient medical attention in a timely manner. That patient’s particular insurance plan is not considered by the emergency medical provider when determining which hospital to take the patient to. It is not until the patient receives their medical bills that they learn whether or not the hospital along with its physicians accepted their insurance. In cases of air ambulance emergency medical services, where the patient is generally in an especially acute condition, there is even less likelihood of insurance consideration. As a result of these scenarios, countless Americans faced numerous surprise medical bills. They were treated by out-of-network physicians despite having no control due to their health circumstances and the general lack of transparency in many health systems. Over the years 2010 to 2016, it was found that an average of “39% of emergency department visits to in-network hospitals resulted in an out-of-network bill.” By 2016, this percentage rose to 42.8%. [1] It is especially important to note that impoverished and otherwise marginalized groups face even worse risks with surprise medical bills. A survey conducted on Americans' ability to pay these surprise bills found that “21 percent of low-income respondents, 19 percent of African Americans, and 17 percent of respondents in rural areas were unable to do so.” The lasting impacts of these disparities are detrimental, contributing to systemic barriers that prolong poverty in the United States. As medical bill debt worsens, future generations are impacted and ultimately bear the brunt of this hardship. So, President Joe Biden created the executive order “On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government'' which called on the Department of Health and Human Services to examine its role in “perpetuating systemic barriers to opportunities and benefits of people of color and other underserved groups.” [2] The aforementioned scenarios and circumstances regularly occurred with no end in sight up until the passage of a new federal law in July 2021: the No Surprises Act. Through subsequent cases Texas Medical Association, et al., v. United States Department of Health and Human Services, (TMA II) and (TMA III), this paper will consider the history, contents, and critiques of the No Surprises Act and discuss the implications of such an important yet criticized piece of legislation.
I. Background
i. Public Health Service Act of 1944 - U.S.C. Title 42
Public health laws in the United States arose early on in the country’s history. With each new piece of public health legislation, the landscape of public health regulation and oversight has continuously developed and grown over time. [3] The very first piece of public health legislation, the Act of Relief of Sick and Disabled Seamen, was signed into law by President John Adams in 1798 and intended to improve the health of immigrants and sailors. Eventually, The United States Public Health Service (USPHS) Commissioned Corps was formally established in 1889. [4] Then, in 1944 the U.S. Public Health Service Act was passed which “consolidated and revised all existing legislation relating to Public Health Service.” [5] The USPHS is globally the most robust public health program with its “healthcare delivery, research, regulation, and disaster relief.” [6] The Public Health Service Act set the groundwork for future public health laws including the No Surprises Act.
ii. Administrative Procedure Act - 5 U.S.C. § 551-559
The Administrative Procedure Act (APA) is the federal law overseeing all procedures of administrative law. It outlines the manner in which federal administrative agencies can design rules as well as adjudications. The APA works to keep future laws reasonable and just. It creates clear definitions for rulemaking and adjudication. [7] Rulemaking must follow the “notice-and-comment” outline which is a regimented four-step process. First, an agency must issue a notice of proposed rulemaking. Second, the agency must provide an opportunity for public comment on the proposed rule. Third, the agency will consider and take into account the comments it receives when developing its final rule. Finally, the agency will publish its final rule. [8] Additionally, the scope of this regulation includes administrative and management actions. It specifically governs both formal and informal rulemaking and adjudication. Every law created in the United States, including the NSA, must adhere to the guidelines of this section of the Code. Laws or portions of a particular law found to be in possible violation of the APA risk being vacated [9] – which is the foundation of the later discussed Texas Medical Association lawsuits brought against the NSA.
iii. Employee Retirement Income Security Act (ERISA) of 1974 - 29 U.S.C. Chapt. 18
ERISA creates a set of protections for retired individuals by establishing a set of baseline standards in retirement and health plans created by private entities. This Act ensures that individuals are fully informed on all of the different aspects of their given plan. Beneficiaries are given a clear set of rights through ERISA that guarantees their autonomy. In the event an individual’s plan ends or a particular benefit is stopped, the Pension Benefit Guaranty Corporation will ensure the individual continues to receive funding for that given benefit. [10] ERISA details the relationship between federal income tax with the pension plans provided by private entities. [11] As of 2013, about 2.4 million health plans were regulated by ERISA. This value corresponds to the 59% of Americans who receive health benefits from their job. [12] Almost every healthcare plan provided by private industry is overseen by ERISA. Healthcare plans are required by ERISA to explicitly inform beneficiaries of the costs they are expected to pay as well as their provider networks and claims process. [13] Therefore, the NSA largely impacted the rights protected by ERISA and created additional benefits to specifically protect health insurance plan coverage and related payments.
iv. No Surprises Act - 26 U.S.C. § 9816
1. Overview
The No Surprises Act (NSA) was passed in 2021 in an effort to protect Americans from surprise medical bills related to treatment from out-of-network physicians that they likely could not avoid or were never notified of. The focus was on bills tending to arise from emergency medical treatments due to the unplanned nature of these treatments and the lack of regard for insurance in emergency settings. The NSA is a collaborative result of the Departments of Health and Human Services, Labor, and Treasury (the Departments). Existing legislation that was notably impacted by this law includes sections of the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act of 1944 (PHS). [14] This Act targeted surprise bills in both non-emergency and emergency settings in which the hospital facility was in-network, but the physician providing care was out-of-network. The NSA also addresses out-of-network care received related to air ambulance services. This branch of the emergency medicine network plays a vital role in delivering timely transport to critically ill patients, but also can be very expensive. The NSA created multiple approaches to addressing and reducing surprise bills. It created the independent dispute resolution (IDR) process which is a method of arbitration where health insurance companies and health systems can discuss and ultimately agree on a payment amount. There is also a separate IDR process for uninsured patients in which discussions occur directly between the patient and the health provider. Some additional notable aspects of the NSA include its insurer decision appeal process, the requirement of “good faith estimates,” and its barring out-of-network health systems from balance billing unless certain “notice and consent requirements” are met.
2. Independent Dispute Resolution (IDR) & Qualified Payment Amount (QPA)
The IDR comes into play if the payment disagreements on cost-sharing amounts and related balance billing cannot be resolved if a state does not have an All-Payer Model Agreement (Social Security Act § 1115A) or open negotiations are unsuccessful. The All-Payer Model Agreement establishes a uniform cost, regardless of an individual's type of insurance, for a particular service across an entire state. The Centers for Medicare and Medicaid work with individual states to set these payment structures, which leads to payments varying across states. Once the decision is made to move forward with an IDR, a federally approved entity is selected to facilitate the process. Prior to recent resolutions, the IDR entity was given a strict set of rules on how to make a decision. The key aspect of the guidelines that caused a major point of contention is the qualifying payment amount (QPA). A QPA is the monetary standard insurance companies use, adjusted for the geographic area, to set payments for particular services in a given specialty. It is the amount that an in-network hospital or physician would receive and a calculation strictly created and utilized by the insurance industry for billing purposes. [15] IDR arbitrators were given six factors to consider when deciding payment disputes and reviewing the amounts presented to them by each party (health system and insurers). Arbitrators were explicitly instructed to first consider the proposed amounts relative to the QPA. Then, they were to consider the other factors including level of training, acuity of disease, good faith efforts, scope of service, and market share of the provider as well as any other additional information either party submitted. [16]
II. Litigation & Related Rulings
Despite its best efforts to improve the economic situation of patients, the NSA immediately was criticized harshly by hospitals and providers. Although physicians wanted their patients to have better experiences with the health system, certain aspects of the NSA were potentially very harmful to their practices and livelihood as healthcare providers. Multiple parties were outraged by the obvious imbalance in the NSA. The primary issues health systems had were concerning the IDR process, specifically the manner in which arbitrators were instructed to make decisions as well as some of the particular information they were expected to review.
Former AMA president, Dr. Jack Resnick Jr., stated that NSA “conflict[ed] with the letter of the law [NSA]” by “ignor[ing] the Act’s requirements for a balanced and independent arbitration process” and described the IDR process as “misguided.” He further voiced his concerns by saying, “We remain very concerned that the implementation of the statute has not supported physicians’ ability to meaningfully engage in the dispute resolution process, contrary to the intent of Congress.” [17] Despite the NSA’s efforts to create a fair and equal arbitration process, physicians found themselves at a blatant disadvantage in these discussions. The emphasis of the QPA, a compensation value generated by insurance companies, as the primary form of comparison for disputed medical bills automatically gave insurance companies the upper hand. The lack of a non-neutral comparison for payment resulted in a biased groundwork before the arbitration process officially began. But the original NSA wording was not just a minor convenience for physicians, it had the potential to be detrimental. Notably in rural areas that already suffer from minimal health care options, physicians struggle with compensation due to the nature of the geographic context they are working in. So when physicians were at risk of receiving significantly less payments under the NSA due to the flawed arbitration process, they became concerned about the plausibility of their ability to continue to function normally. In a Ways & Means hearing on the flaws of the NSA, an emergency room doctor named Dr. Bleir explained that “Without that additional reimbursement, we aren’t able to potentially provide the same level of care that we ordinarily would want to those rural emergency departments who are already suffering for a number of different reasons.” [18] And it was not just physicians at risk but rather a much larger party intended to be protected by this law: patients. A Nevada hospital called Renown Health explained, “[that the rule] will have a significant and devastating impact to both Renown’s financial viability, as well as our ability to serve the healthcare needs of our community.” [19] Hospitals shutting down and reducing access to healthcare would be a serious loss and unintended consequence of the NSA. So, various medical groups agreed that it was necessary to address these discrepancies in an effort to avoid such drastic repercussions. Texas Medical Association (TMA) filed three separate lawsuits, all under the name, Texas Medical Association, et al., v. United States Department of Health and Human Services. The first appeal, which was ultimately dismissed, was filed in 2022 (TMA I). The following two appeals (TMA II and TMA III) were successfully filed in 2023. [20]
i. Texas Medical Association, et al., v. U.S. Department of Health and Human Services (TMA II) (2023)
Plaintiffs (Texas Medical Association) argued that the current wording of the NSA strongly favored insurance companies. Federally certified IDR entities were given clear instructions on the factors they were to consider for forming a decision on the final payment for a “qualified IDR item or service.” [21] Arbitrators were instructed to compare the proposed amounts to the appropriate QPA and "select the offer closest to the [QPA]" - making the QPA the principal factor of consideration in the IDR. The limitations enforced on arbitrators created unlawful and biased “guardrails” [22] under the APA according to the plaintiffs. Since the QPA was a value created by insurance companies, it inherently favored the insurance company’s proposed payment. It is important to note that QPA estimates are generally lower than physicians proposed payments which may benefit the patient, but seriously hurt providers. Plaintiffs argued that strictly following the QPA would “threaten the viability of providers’ practices.” Additionally, plaintiffs claimed that the NSA was in direct violation of the APA’s mandated “notice-and-comment” (see section II B). [23] So, it was necessary to amend the NSA due to the laws in place under the APA. Ultimately, the court ruled that the original NSA rules “places its thumb on the scale for the QPA, requiring arbitrators to presume the correctness of the QPA and then imposing a heightened burden on the remaining statutory factors to overcome the presumption.” [24] Although the QPA was just one of multiple factors to be considered by IDR entities, it was unjustifiably and incorrectly given more power which would influence arbitrations. In the final opinion, it was stated “Treat[ing] one of the five statutory factors in such a dramatically different fashion distorts the judgment Congress directed.” Therefore, the Act was found to be violating its own law. Certain language in NSA was vacated to amend the described issues. [25] The basis for the decision in this lawsuit was the NSA itself. Plaintiffs pointed to the goals and mission of the NSA and highlighted its direct violations of itself. These facts led the court to amend the Act in an effort to make its content and implementation reflective of its goals.
ii. Texas Medical Association, et al., v. U.S. Department of Health and Human Services (TMA III) (2023)
In this third lawsuit, TMA and other plaintiffs further challenge the NSA, specifically the calculation of the QPA. Although the importance of the QPA was slightly reduced through earlier challenges and rulings, the QPA itself is still inherently unjust. Providers argued that insurance companies are able to “artificially depress the QPA in conflict with the Act, again tilting the arbitration process in insurers’ favor and resulting in unacceptably lower payments to providers.” [26] Insurers have the ability to depress the QPA - which is based on contracted rates - by including “ghost rates” which are “rates for items or services that providers have no intention to provide.” According to physicians and hospitals, “ghost rates are generally below fair market value because providers have no incentive to robustly negotiate them.” The inclusion of “ghost rates” is not permitted under the NSA as only “provided” services are to be considered in the QPA calculation. Additionally, this lawsuit considered multiple other critiques of the NSA: insurers’ ability to lower the QPA by including out-of-specialty rates which are normally low; insurers’ ability to lower the QPA by the exclusion of reward payments (e.g. incentives and bonuses); utilize third-party administrators to calculate lowest possible QPA, etc. All of these complaints resulted in various sections of the NSA being vacated under the APA. [27] Because Act conflicted with itself repeatedly, the court sided with the plaintiffs for the majority of the complaints. This most recent change to the QPA is arguably of the greatest impact on the NSA and its efforts to create a truly balanced and unbiased arbitration process for both parties involved. [28]
III. Present/Future Implications
i. Recent Update on Ongoing Criticism
The NSA continues to evolve and adapt. In September 2023, the involved Departments proposed an increase to the administrative fees in the IDR process as well as an increase to the fees IDR entities charge. This fee increase could potentially reduce a party’s access to the IDR process due to an inability to afford the higher administrative fee. In a government-run program intended to save Americans money, it is unacceptable and counterintuitive that a process created to save money should cost too much to engage with. If a group chooses to enter the IDR process, it is unlikely they have the means to spend more money in addition to what they have already unexpectedly lost. Additionally, increasing fees will make it more difficult for the initiating party to ensure the non-initiating party engages in the process - since the non-initiating party was never interested but they will have to pay regardless. Although it is understandable that IDR entities would increase their costs due to a variety of reasons, most obviously inflation, it should not come out of the pocket of individuals but rather the federal government. At the time of writing this article, all IDR processes have been “temporarily suspended” by the Centers for Medicare & Medicaid Services due to ongoing legal proceedings on the possible violations of this ruling. [29
ii. Biden-Harris Administration
The Biden-Harris Administration is actively working to improve the NSA to “protect patients from junk health insurance and unfair billing practices.” In collaboration with the Departments, the administration has proposed multiple changes to the NSA on the topics of communication between parties, open negotiation, IDR initiation, IDR eligibility and related administrative fees, and the process of batching. Their goal is to continue to make the IDR process more equitable, accessible, and efficient. [30]
IV. Conclusion
The No Surprises Act is a highly important piece of healthcare legislation that impacts the day-to-day lives of most Americans. Despite its flaws, many of which have been amended over the past year, its mission to improve the patient experience and protect Americans from surprise medical bills should be applauded. Specifically, its work to reduce the financial burden on impoverished and otherwise marginalized groups is essential to the country’s work to increase health equity in underserved communities. These improvements to health equity are quintessential to breaking down systemic barriers still present in the United States. In a health system that is already significantly more expensive than other similar high-income countries, it is illogical that Americans have been slammed for years with even larger, unreasonable medical bills. In a shift from its normal stance on healthcare, the United States government decided to step in. While this step was necessary for the sake of Americans, healthcare systems were inadvertently adversely targeted. Despite the Departments’ effort to create a fair arbitration process, the original use of a QPA as the primary point of comparison and then later as a general factor in the decision process greatly angered healthcare systems. Although health system’s out-of-network prices were often deemed unreasonable, the QPA value often fell on the opposite end of the spectrum - significantly lower than the marketplace cost of a particular service. This tactic was utilized by insurance companies to reduce their costs which resulted in healthcare systems’ livelihood becoming jeopardized due to unacceptably low payments. If physicians and hospitals are forced to focus on the bureaucratic issues of payment disputes and the QPA model, it will detract from their ability to care for patients.
The federal government must continue to actively work to fairly balance the power of healthcare systems and insurance companies to protect Americans while also not hurting either entity. Healthcare systems and their success are vital to the health of Americans. Private insurance companies, although business-like, are also essential to Americans' ability to access healthcare under the current structure of healthcare in the United States. It is crucial that the government continues to check insurance companies as they grow in size and power to ensure they are properly supporting their enrollees while also not taking advantage of health providers. The federal government must make every effort possible to maintain a reasonable and equitable balance between healthcare systems and insurance companies to support Americans’ health.
Endnotes
[1] Eric C Sun et al., “Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in in-Network Hospitals,” JAMA internal medicine, November 2019, https://pubmed.ncbi.nlm.nih.gov/31403651/.
[2] Personnel Management Office et al., “Requirements Related to Surprise Billing; Part I,” Federal Registrar: The Daily Journal of the United States Government, August 13, 2021, https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i.
[3] NIH, “Public Health Service Act,” National Cancer Institute, February 16, 2016, https://www.cancer.gov/about-nci/overview/history.
[4] USPHS, “History,” Commissioned Corps of the U.S. Public Health Service, accessed November 21, 2023, https://www.usphs.gov/history.
[5] NIH, “Public Health Service Act,” National Cancer Institute, February 16, 2016, https://www.cancer.gov/about-nci/overview/history.
[6] USPHS, “History,” Commissioned Corps of the U.S. Public Health Service, accessed November 21, 2023, https://www.usphs.gov/history.
[7] Tex. Med. Ass'n v. United States HHS, No. 6:22-cv-372-JDK, 2023 U.S. Dist. LEXIS 19526 (E.D. Tex. Feb. 6, 2023)
[8] ACUS. “Notice-and-Comment Rulemaking.” ADMINISTRATIVE CONFERENCE OF THE UNITED STATES, May 2021. https://www.acus.gov/sites/default/files/documents/IIB014-Rulemaking.pdf.
[9] LII. “Administrative Procedure Act.” Legal Information Institute. Accessed November 21, 2023. https://www.law.cornell.edu/wex/administrative_procedure_act.
[10] DOL, “Employee Retirement Income Security Act (ERISA),” Retirement Plans Benefits and Savings, accessed November 21, 2023, https://www.dol.gov/general/topic/retirement/erisa#:~:text=The%20Employee%20Retirement%20Income%20Security,for%20individuals%20in%20these%20plans.
[11] LII. “ERISA.” Legal Information Institute. Accessed November 21, 2023. https://www.law.cornell.edu/wex/erisa.
[12] 2 DOL, “Employee Retirement Income Security Act (ERISA),” Retirement Plans Benefits and Savings, accessed November 21, 2023, https://www.dol.gov/general/topic/retirement/erisa#:~:text=The%20Employee%20Retirement%20Income%20Security,for%20individuals%20in%20these%20plans.
[13] E. Napoletano, “What ERISA Means for Your Retirement Plan,” ed. John Schmidt, Forbes, May 31, 2022, https://www.forbes.com/advisor/retirement/erisa-employee-retirement-income-security-act/.
[14] Ibid.
[15] CMS, “Overview of Rules & Fact Sheets,” CMS.gov, October 27, 2023, https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets.
[16] Henry, Tanya Albert. “Court: No Surprises Act Final Rule Favors Insurers, Must Be Revamped.” American Medical Association, March 1, 2023. https://www.ama-assn.org/delivering-care/patient-support-advocacy/court-no-surprises-act-final-rule-favors-insurers-must-be.
[17] Ibid.
[18] Johnny Rubin, “Top Five Moments from Ways and Means Hearing on Flawed Implementation of the No Surprises Act,” House GOP Committee on Ways and Means, September 21, 2023, https://gop-waysandmeans.house.gov/top-five-moments-from-ways-and-means-hearing-on-flawed-implementationof-the-no-surprises-act/.
[19] Melinda Hatton and Molly Smith, “Blog: Why Hospitals and Physicians Are Filing Suit over No Surprises Act Final Rules That Jeopardize Patient Access to Care: AHA News,” American Hospital Association | AHA News, December 9, 2021, https://www.aha.org/news/blog/2021-12-09-blog-why-hospitals-and-physicians-are-filing-suit-over-no-surprises-act-final.
[20] Tex. Med. Ass'n v. United States Dep't of Health & Hum. Servs., No. 6:22-cv-450-JDK, 2023 U.S. Dist. LEXIS 149393 (E.D. Tex. Aug. 24, 2023)
[21] LII, “26 U.S. Code § 9816 - Preventing Surprise Medical Bills,” Cornell Legal Information Institute, accessed November 21, 2023, https://www.law.cornell.edu/uscode/text/26/9816.
[22] “Texas Medical Association et al. v. U.S. Department of Health and Human Services et al. (TMA II),” Health Care Litigation Tracker, October 31, 2023, https://litigationtracker.law.georgetown.edu/litigation/texas-medicalassociation-et-al-v-u-s-department-of-health-and-human-services-et-al-tma-ii/.
[23] Tex. Med. Ass'n v. United States HHS, No. 6:22-cv-372-JDK, 2023 U.S. Dist. LEXIS 19526 (E.D. Tex. Feb. 6, 2023)
[24] “Texas Medical Association et al v. United States Department of Health and Human Services et al, No. 6:2022cv00372 - Document 99 (E.D. Tex. 2023),” Justia Law, 2023, https://law.justia.com/cases/federal/district-courts/texas/txedce/6:2022cv00372/217452/99/.
[25] “Texas Medical Association et al v. United States Department of Health and Human Services et al, No. 6:2022cv00372 - Document 99 (E.D. Tex. 2023),” Justia Law, 2023, https://law.justia.com/cases/federal/district-courts/texas/txedce/6:2022cv00372/217452/99/.
[26] Tex. Med. Ass'n v. United States Dep't of Health & Hum. Servs., No. 6:22-cv-450-JDK, 2023 U.S. Dist. LEXIS 149393 (E.D. Tex. Aug. 24, 2023)
[27] Ibid.
[28] Alexis Boaz, “Texas Federal Court Issues Fourth Ruling Invalidating Parts of the Administration’s No Surprises Act Regulations,” Legal News & Business Law News, September 7, 2023, https://www.natlawreview.com/article/texas-federal-court-issues-fourth-ruling-invalidating-parts-administration-s-no.
[29] AHA, “CMS Proposes Changes to No Surprises Act IDR Fees in Response to Court Ruling: AHA News,” American Hospital Association | AHA News, September 21, 2023, https://www.aha.org/news/headline/2023-09-21-cms-proposes-changes-no-surprises-act-idr-fees-response-court-ruling.
[30] Assistant Secretary for Public Affairs (ASPA), “Biden-Harris Administration Advances Efforts to Improve the Surprise Billing Payment Dispute Process,” HHS.gov, October 27, 2023, https://www.hhs.gov/about/news/2023/10/27/biden-harris-administration-advances-efforts-improve-surprise-billingpayment-dispute-process.html.