Urology Coding Alert

Louisiana Subscriber

Answer: Balance billing is a huge problem for patients, and sometimes individual patient’s cases make the news. The Coronavirus Aid, Relief, and Economic Security (CARES) Act addressed balance billing for COVD-19 cases, and the Biden-Harris administration has recently released an interim rule that addresses the practice.

“These surprise billing protections apply to [patients] if [patients] get [their] coverage through [their] employer (including a federal, state, or local government), or through the federal Marketplaces, state-based Marketplaces, or directly through an individual market health insurance issuer,” the Centers for Medicare & Medicaid Services (CMS) says in a recent press release. Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, and TRICARE already prohibit balance billing.

The rule requires insurance carriers to cover emergency services without prior authorization and regardless of whether the facility or provider is in-network.

“This rule also protects people from excessive out-of-pocket costs by limiting cost-sharing for out-of-network services to in-network levels, requiring cost-sharing for these services to count toward any in-network deductibles and out-of-pocket maximums, and prohibiting balance billing under certain circumstances,” CMS says.

“The protections in this rule apply to most emergency services, air ambulance services from out-of-network providers, and non-emergency care from out-of-network providers at certain in-network facilities, including in-network hospitals and ambulatory surgical centers,” CMS says.

If the rule becomes final, certain providers will be required to provide patients with a one-page notice outlining the regulations applicable to that provider/facility regarding balance billing, any applicable state laws, and how to contact appropriate state or federal agencies if the provider or facility has violated the requirements.

Right now, the rule is set to take effect Jan. 1, 2022. The document is available to read but, as of press time, was not published in the Federal Register and is thus not yet available for public comment.

The document is available at www.cms.gov/files/document/cms-9909-ifc-surprise-billing-disclaimer-50.pdf.