Surprise Billing Regulation



When a patient receives an unexpected medical bill from a practice/ provider/ facility that has not participate with the patient’s insurance coverage, is known as Surprise Billing or Balance Billing. It is estimated that one out of every six emergency room visits and inpatient hospital stays bills services from at least one out-of-network provider, leading to surprise medical bills. It happens that nonparticipating practice/ provider involved in a patient’s overall care, however, their services are performed at a participating facility. At present, surprise billing or balance billing is prohibited by Medicare, Medicaid, TRICARE, Veterans Affairs Health Care and Indian Health Services.


No Surprise Act (NSA):


No Surprises Act (NSA) regulates surprise billing in healthcare settings and also mandates full transparency of coverage regulations for patients. The NSA was signed into law on December 27, 2020, as the part of the federal Consolidated Appropriations Act, 2021. The No Surprise Act (NSA) guarantees protection of patients from noticeable types of surprise bills by ensuring that patients incur the same costs for out-of-network practice/ provider/ facility as they do for in-network practice/ provider/ facility The No Surprise Act (NSA) also continues the protections guaranteed under the Affordable Care Act (ACA), and also eliminating surprise medical bills to patients.


Interim Final Rule (IFR):

On July 1, 2020, the U.S. Department of Health and Human Services (HHS), Labor, Treasury, and the Office of Personnel Management issued Requirements Related to Surprise Billing; Part I, an interim final rule (IFR) that is a initial leap toward implementation of the No Surprises Act (NSA). Part II of the rule will be published after a 60-day comment period following publication in the Federal Register, and one more rule is also expected before January 1, 2022, to finish laying all the groundwork for No Surprise Act (NSA).


Protection Of Patient:


The IFR prohibits as mentioned here in below:

1. Surprise billing for emergency services, notwithstanding of where they are provided

2. High out-of-network cost sharing for emergency and non-emergency services by keeping costs no higher than in-network rates

3. Out-of-network charges for ancillary care (e.g., anesthesiologist) at any in-network facility

4. Other out-of-network charges without advance notice

5. If a patient’s health plan covers any benefits for emergency services, the IFR requires nonparticipating emergency services to be covered:

  • Without any prior authorization

  • Notwithstanding of whether a provider or facility is in-network

  • Without limitations

Section 102 of the NSA has very wide scope of the of emergency services definition including emergency services provided at an independent freestanding emergency department and urgent care centers that are permitted to provide emergency services under state laws.


From January 1, 2022, consumer protections in this rule will take effect. The regulations are applicable to the group health plans and health insurance issuers for the plans beginning on or after Jan. 1, 2022. It is also applicable to FEHB (Federal Employees Health Benefits) program carriers for the contract years beginning on or after Jan. 1, 2022. They are also applicable to Practice/ providers/ facilities from the date January 1, 2022.


The federal government is presently working on guidance to all the stakeholders prior to the effective date. Also expect to see more rules that continue to address consumer protections in the coming months.


Resources:

https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills

https://www.cms.gov/files/document/cms-9909-ifc-surprise-billing-disclaimer-50.pdf

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