ED Coding and Reimbursement Alert

Air ambulances are also facing tighter payment regulation, says Catherine Howden, director of CMS News and Media Group, quoting a 2019 study by the Government Accountability Office (GAO) that found that the median price charged by air ambulances was nearly $40,000, and 70 percent of these transports were considered out of network for patients.

However, individual providers administering services for care that isn’t emergent will have new obligations as well. The interim final rule also says that nonemergency services provided by out-of-network providers must be treated like in-network services, unless the insured individual is provided notice and gives consent, says Lisa A. Lucido at Hall Render, in online analysis of the interim final rule.

Balance Billing Still an Option in Some Circumstances

The rules described here have a pretty broad purview, applying to group health plans, health insurance issuers offering group or individual health insurance coverage (including grandfathered plans), with plan or policy years beginning on or after Jan. 1, 2022. Healthcare providers and facilities (and air ambulance services) will also be held to these rules beginning Jan. 1, 2022.

The Federal Register says “… balance billing continues to be permitted, unless prohibited by state law or contract, in circumstances where these interim final rules do not apply, such as for non-emergency items or services provided at facilities that are not included within the definition of health care facility in these interim final rules.”

The spirit of the new law is to protect patients from unexpected bills for care they need and receive, but the legislation holds space for patients who may want to pursue care out of network, as long as the provider in question is transparent with the patient ahead of time.

“To reduce burden and facilitate compliance with these disclosure requirements, the Departments are concurrently issuing a model disclosure notice that health care providers, facilities, group health plans, and health insurance issuers may, but are not required to, use to satisfy the disclosure requirements regarding the balance billing protections,” the interim final rule says.

The comment period on the model forms closed Aug. 12.

Patients Can Lodge Complaints

Although the No Surprises Act and this interim final rule involve multiple federal agencies, there will be one central system for patients to lodge complaints about providers who violate the new rules. Right now, the specifics haven’t yet been fully determined; HHS and CMS are still deciding the appropriate period for a time limit on complaints.

Prep for the Adjustment Now

Keep in mind that some payers may take this as an opportunity to make changes to current agreements or renegotiate payment rates, Lucido says.

Evaluate carefully whether you want to be in network or out of network with individual payers. Besides assessing your agreements and payment rates with individual payers, you should start preparing how you’re going to communicate with patients.

Providers need to make sure that their websites include surprise billing disclosures by Jan. 1, 2022. You should prepare your model notice and disclosure forms as well before you need to start deploying them, by the beginning of next year.

Keep an eye out for further regulations to be announced later this year, which may include more information on the dispute resolution process, as well as enforcement, Lucido says.

Read the final rule here www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i.