AHIP wants more time for insurers to implement the interim final rule on surprise billing 

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AHIP is concerned about the timeline for an interim final rule on surprise billing and has asked the Department of Health and Human Services and other agencies for safe harbor for insurers to implement provisions in the rule through 2023, rather than the scheduled start date of 2022.

The law requires consumers to be protected from receiving surprise medical bills beginning on January 1, 2022. 

"We are fully supportive of that requirement and agree that consumers should NOT receive surprise medical bills beginning on that date while health insurance issuers work behind the scenes with providers and facilities to comply with these new requirements," AHIP said in a September 3 letter to HHS and to the Departments of Health and Human Services, Treasury, Labor and the Office of Personnel Management.

"We do, however, have significant concerns about whether health plans have sufficient lead time and regulatory clarity to implement and operationalize many of the non-consumer facing portions of these and subsequent regulations. We ask that there be a good faith safe harbor in place to implement those provisions of the law through 2023."  

WHY THIS MATTERS

The No Surprises Act was enacted as part of the Consolidated Appropriations Act of 2021. 

The interim final rule, "Requirements Related to Surprise Billing; Part I," was published July 13 in the Federal Register.

One of the biggest areas of surprise medical bills for consumers is from emergency care, when services are unknowingly given by an out-of-network provider.

"Ending surprise medical bills for emergency services is a top priority for our members," AHIP said. "To ensure this is achieved properly and smoothly, the final regulations must make clear what constitutes emergency services, including post-stabilization care …. We are concerned that the existing regulatory definitions cannot readily be coded into routine health insurance claims and are subjective depending on the determination of the attending physician."

AHIP also said it would take more time than three months to operationalize the qualifying payment amount methodology. There are too many outstanding implementation questions such as, what constitutes a contracted rate? 

Also, AHIP said, each healthcare service and supply code requires a separate calculation by geographic area and market segment. It would then be needed to be tested for accuracy and loaded into the claims processing systems for calculation of the member's cost-sharing. 

THE LARGER TREND

In July, the interim final rule was released with the goal to restrict excessive out-of-pocket costs to consumers from surprise billing and balance billing. 

Surprise billing happens when people unknowingly get care from providers that are outside of their health plan's network and can happen for both emergency and non-emergency care. 

Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. The rule extends similar protections to Americans insured through employer-sponsored and commercial health plans.

The interim final rule bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.

It bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as coinsurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.

It bans out-of-network charges for ancillary care, such as for an anesthesiologist or assistant surgeon, at an in-network facility in all circumstances.

It bans other out-of-network charges without advance notice. 

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com