General Surgery Coding Alert

You can still bill out-of-network balance — with permission.

Known as the No Surprises Act, a recent Health and Human Services (HHS) final rule about “surprise” or “balance” billing outlines new obligations you’ll face in your surgery practice beginning Jan. 1, 2022.

“Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs. The Biden-Harris Administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises,” said Xavier Becerra, Secretary of Health and Human Services (HHS).

Read on to learn how the rule might impact your practice, and what you can do to prepare.

Know the Basics:

The legislation says that emergency care must be billed at in-network rates, without prior authorization, for facilities, as well as the individuals providing services.

However, individual providers providing 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.

The rule encompasses equipment and devices, as well as services like telemedicine, imaging, laboratory, and pre- and postop — regardless of whether the provider furnishing the services is present at the facility, she says.

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.

Not All Balance Billing is Bad

The expectations described in the final rule have a pretty broad purview, applying to healthcare providers, facilities, air ambulance services, group health plans, and health-insurance issuers offering group or private coverage.

The rule states “… 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.

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 with providers who violate the new rules.

Right now, the specifics haven’t yet been fully determined; HHS and the Centers for Medicare & Medicaid Services (CMS) are still deciding the appropriate period for a time limit on complaints. HHS plans to respond to comments and provide further direction within 60 business days, according to the rule.

Do These 4 Things Now

Payers may take this rule as an opportunity to make changes to current agreements or renegotiate payment rates, Lucido says. That means you need to be prepared by taking the following steps:

• 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 also prepare your model notice and disclosure forms 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.