The Biden administration on Thursday issued an interim final rule with comment period to further implement the No Surprises Act – a consumer protection law that helps curb the practice of surprise medical billing.
The rule – which goes into effect Jan. 1 – builds on an interim final rule issued back in July that bans balance billing for emergency services and prohibits out-of-network charges for items and services provided by out-of-network providers at an in-network facility, except if the patient grants consent.
The rule details a process that will take patients out of the middle of payment disputes, provides a transparent process to settle out-of-network (OON) rates between providers and payers, and outlines requirements for health care cost estimates for uninsured (or self-pay) individuals. A payer and provider can initiate a 30-day open negotiation period to determine an out-of-network rate. If the parties can’t reach an agreement after that period, either party can initiate the independent dispute resolution process.
“The parties then may jointly select a certified independent dispute resolution entity to resolve the disputes,” according to a fact sheet on the rule.
After an arbiter is selected, both the payer and provider will submit the amount they believe the service should cost. The arbiter will then select one of the amounts as the out-of-network charge. The arbiter must begin with the presumption that the qualified payment amount, which is the insurance plan’s median contracted rate for the same or similar service in an area, is the appropriate out-of-network charge.
Other consumer protections in the rule include a payment dispute resolution process for uninsured or self-pay individuals. It also adds protections in the external review process so that individuals with job-based or individual health plans can dispute denied payment for certain claims.
We are currently analyzing the rule and will follow up with a full breakdown of the provisions.
Biden Administration Issues “Surprise Billing: Part II” Interim Final Rule
October 1, 2021 8:30 am
The Biden administration on Thursday issued an interim final rule with comment period to further implement the No Surprises Act – a consumer protection law that helps curb the practice of surprise medical billing.
The rule – which goes into effect Jan. 1 – builds on an interim final rule issued back in July that bans balance billing for emergency services and prohibits out-of-network charges for items and services provided by out-of-network providers at an in-network facility, except if the patient grants consent.
The rule details a process that will take patients out of the middle of payment disputes, provides a transparent process to settle out-of-network (OON) rates between providers and payers, and outlines requirements for health care cost estimates for uninsured (or self-pay) individuals. A payer and provider can initiate a 30-day open negotiation period to determine an out-of-network rate. If the parties can’t reach an agreement after that period, either party can initiate the independent dispute resolution process.
“The parties then may jointly select a certified independent dispute resolution entity to resolve the disputes,” according to a fact sheet on the rule.
After an arbiter is selected, both the payer and provider will submit the amount they believe the service should cost. The arbiter will then select one of the amounts as the out-of-network charge. The arbiter must begin with the presumption that the qualified payment amount, which is the insurance plan’s median contracted rate for the same or similar service in an area, is the appropriate out-of-network charge.
Other consumer protections in the rule include a payment dispute resolution process for uninsured or self-pay individuals. It also adds protections in the external review process so that individuals with job-based or individual health plans can dispute denied payment for certain claims.
We are currently analyzing the rule and will follow up with a full breakdown of the provisions.