Biden Administration advances new protections against surprise medical bills

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The Biden Administration, through the Departments of Health and Human Services, Labor and Treasury, and the Office of Personnel Management, has issued an interim final rule with a comment period to further implement the No Surprises Act, introducing a dispute resolution process for self-pay patients and the uninsured.

This rule details a process that aims to take patients out of the middle of payment disputes, establishing a process to settle out-of-network rates between providers and payers. It also outlines requirements for healthcare cost estimates for uninsured or self-pay individuals.

Other consumer protections in the rule include a payment-dispute-resolution process for uninsured or self-pay individuals. It also adds protections in the external review process so that individuals with job-based or individual health plans can dispute denied payment for certain claims.

Dr. Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight, said during a press conference Thursday that the ability to resolve payment disputes will be especially critical for Americans.

"This benefits people directly," Montz said. "They will only be liable for the in-network cost-sharing amount, like their copay. Consumers can plan for and compare costs. For the uninsured or those who are self-pay, they can get cost estimates before they receive care."

Under the new dispute resolution process, someone who's uninsured would have the right to a good faith estimate from a provider or facility about the services they intend to receive. The estimate would need to include not just the specific service, but any kind of follow-up services that would be offered throughout the totality of the episode of care. 

That estimate, said Montz, is key to engaging in the dispute resolution process. If a service is rendered and the bill is greater than expected – at $400 or more – the patient can enter into dispute resolution.

HHS Assistant Secretary for Legislation Melanie Egorin said Thursday that the bill will also limit high out-of-network costs.

"This is something that's going to make a tangible difference in people's lives," said Egorin, "promoting price transparency and bringing down healthcare costs … to have a pretty transparent and competitive process."

WHAT'S THE IMPACT?

The rule is the third in a series by the Departments and OPM implementing the No Surprises Act, a bipartisan consumer protection law, which the administration directed HHS to prioritize and implement as part of the Executive Order on Promoting Competition in the American Economy. 

In early September, the Departments and OPM issued a rule to help collect data on the air-ambulance-provider industry, in addition to a rule in July on consumer protections against surprise billing. 

Collectively, these rules take effect January 1, 2022, and ban surprise billing for emergency services, as well as certain non-emergency care provided by OON providers at in-network facilities, and limit high OON cost-sharing for emergency and non-emergency services for patients.

The new rule details how the total payment to an OON provider or facility will be determined.

The departments will certify independent dispute resolution entities to conduct payment determinations on a rolling basis. Entities interested in becoming certified by January 1, 2022 can submit their applications by November 1.

The departments are also releasing the Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution Process Under the No Surprises Act. The guidance provides the allowable fees certified independent dispute resolution entities will be able to charge in 2022, as well as the administrative fee that parties to a dispute must pay to access the process.

THE LARGER TREND

Surprise billing occurs when a patient sees an out-of-network provider during an emergency, or in a nonemergency case in which a patient sees an in-network provider but gets care from an out-of-network provider, such as an anesthesiologist.

When a patient receives out-of-network care, many times unknowingly, they may receive the balance of the bill, or the difference between full charges and what's been paid.

What's more, surprise billing may leave many patients vulnerable to the financial burdens presented by a nationwide pandemic. Research shows that 41% of insured adults nationwide were surprised by a medical bill in the past two years and that two thirds of adults worry about their ability to afford an unexpected medical bill.

Congress passed the No Surprises Act in December 2020, which prohibits most surprise out-of-network billing for plan years beginning in 2022. Specifically, it requires plans to apply in-network cost sharing and prohibits out-of-network providers from balance billing on surprise medical bills. 

The act, however, does not apply to bills from ambulances – which is important, because as many as 1.5 million privately insured patients are brought to an emergency room by an ambulance and may be at risk of getting a surprise medical bill each year, according to Kaiser Family Foundation. 

Although the No Surprises Act doesn't address surprise ambulance bills, it does require that a federal advisory committee convene to review and recommend options to protect patients from them.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com