Medicare Compliance & Reimbursement

Know the facts on new patient notification requirements.

You may have thought the feds would let providers get accustomed to the initial policies under the No Surprises Act before issuing more changes. But, that’s not the case — and industry insiders aren’t too happy with the latest round of regulations.

Background: In December 2020, Congress issued the No Surprises Act, which was part of the mammoth Consolidated Appropriations Act, 2021. Next, the Departments of Health and Human Services (HHS), Labor, and Treasury, in tandem with the Office of Personnel Management (OPM), built on that legislation with an interim final rule titled “Requirements Related to Surprise Billing: Part I,” which was published in the Federal Register on July 13 (see Medicare Compliance & Reimbursement, Vol. 47, No. 14).

Now: On Sept. 30, the feds issued another interim final rule with comment period (IFC), implementing more balance billing reforms and expanding the No Surprises Act even further. The latest release — and third actual rule — “Requirements Related to Surprise Billing; Part II,” was published in the Federal Register on Oct. 7, and covers a broad range of topics, “including provisions related to the independent dispute resolution process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review,” a Centers for Medicare & Medicaid Services (CMS) release indicates.

Healthcare disparities remain a hot topic, and a plethora of equity issues related to both the availability and cost of care have been exacerbated during the pandemic. The recent rulemaking aims to eradicate longstanding issues and offer consumers information upfront to aid in their care decision-making, CMS suggests.

“Price transparency is a reality in almost every aspect of our lives except health care,” said CMS Administrator Chiquita Brooks-LaSure in a release. “The Biden-Harris Administration is committed to changing this. With today’s final rule, we are requiring health care providers and health care facilities to provide uninsured patients with clear, understandable estimates of the charges they can expect for their scheduled health care services.”

Consider These Provider-Specific Takeaways

The latest surprise-billing opus focuses on the federal independent dispute resolution (IDR) process between out-of-network (OOS) providers, facilities, and payers. The rule offers a more in-depth definition of the IDR process while setting a timeline, rate structures, and procedures for how it will work.

“Part 2 also addresses requirements for providers to offer a good faith estimate of expected charges for uninsured and self-pay patients and creates a patient-provider dispute resolution process to determine a payment amount when an uninsured or self-pay patient is billed in an amount higher than the good faith estimate,” explains attorney Jeffrey I. Davis with law firm Baker Donelson in online legal analysis.

Here’s a quick overview of four key points you should know:

1. Know the new IDR timeline. The rule outlines a specific time frame based on each particular IDR action. For starters, “the regulations provide that, after 30 days of negotiation, either party may initiate the federal IDR process,” says attorney Lauren M. Moldawer with law firm Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. in online analysis.

Other timelines focus on when to initiate the IDR after failed negotiations; how long the agreement on the IDR entity should take; the department selection of an IDR entity if the parties cannot agree; payment submissions and additional documentation to the IDR entity; payment determinations; and final payment submissions to the applicable party, according to the CMS fact sheet on the rule.

2. Bank on the QPA. The qualifying payment amount (QPA) is central to understanding the new rule and factors into many of the new policies. “The QPA is generally the plan or issuer’s median contracted rate for the same or similar service in the specific geographic area,” CMS says.

In a nutshell, payment determinations by the IDR entity must rely on the QPA and assume its the correct OON amount. “Therefore, it [IDR entity] must select the offer closest to the QPA, unless credible information presented by a party rebuts that presumption and clearly demonstrates the QPA is materially different from the appropriate out-of-network rate,” Moldawer expounds.