Monday, January 30, 2023

Surprise Billing Ban

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Surprise Billing Ban Compliance Date Weeks Away

Surprise billing is a famous topic nowadays. In our previous surprise billing article, we have discussed it deeply. So today we are going to discuss the surprise billing ban. So here we go!

The U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, as well as the Office of Personnel Management, announced the very first interim final rule or set of standards, for the No Surprises Act (NSA), which is expected to go into effect on January 1, 2022. 


The regulation specifies fundamental patient safeguards regarding treatments and cost-sharing for Americans who obtain healthcare via their employers or a global market. Surprise billing is now forbidden by Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, and TRICARE, all of which have their own safeguards in place.

Open-Door Special Forum

The Centers for Medicare & Medicaid Services (CMS) held a special open-door event on December 8 to discuss the purpose, provider obligations, and implementation aspects of the NSA, as well as to enable opportunities for questions and answers (Q&A).

Much of the same subject was discussed as in the interim final regulations for Parts I and II, although there were a few additional features that stuck out:

  • There will be no balance billing for air ambulance services provided by nonparticipating air ambulance companies.
  • When a provider’s network state changes, firms must maintain continuity of care.
  • Facilities must enhance their provider catalogs and refund participants for mistakes that occurred when they depended on an erroneous provider directory and paid a provider bill that exceeded the in-network cost-sharing level.

There are also more details on post-stabilization assistance and non-emergency services.

Services for Post-Stabilization

There was more information supplied on no-balance charging for out-of-network emergency treatment. “Certain post-stabilization operations are deemed emergency medical services and are thus exposed to this ban unless notice and consent criteria are satisfied,” CMS states. Nonparticipating physicians and facilities may balance charge for post-stabilization services only if and only if the following conditions are met:

The medical provider or emergency physician finds that the beneficiary, enrollee, or participant:

  • Is capable of traveling by non-medical or non-emergency healthcare transports to a partnering professional or facility situated within a reasonable distance traveled, taking into consideration the patient’s health condition;
  • Is in a position to receive notification and provide explicit consent. 
  • The nonparticipating practitioner or facility gives the beneficiary, enrollee, or participant a written notification and gets consent that comprises certain material that within the timing and format specified in rules and guidelines; or
  • Any extra state law criteria are met by the provider or institution.

A physician or facility cannot inappropriately charge for things or services provided as a consequence of unanticipated, urgent medical requirements that develop at the time the item or service is provided, regardless of whether the non – participating physician or facility earlier completed the notice and consent criterion. It is important to note that this relates to both urgent and non-emergency operations.

Services for Non-Emergency Situations

Balancing billing for non-emergency treatments by nonparticipating physicians is not permitted at some participating medical institutions.

Nonparticipant non-emergency healthcare providers in a participating medical facility:

  • Recipients, participants, or people involved in group health insurance or group or independent medical insurance coverage who obtained enclosed non-emergency services from a nonparticipating provider during a visit at a participating medical facility for a reimbursement significantly larger than the in-network cost-sharing request for such facilities can indeed be billed or held liable except if observe and assent requirements are satisfied.
  • Cost-sharing is determined as if the entire amount that a participating provider or participating facilities would have assessed was equal to the recognized amount.

Healthcare facilities, outpatient sections of hospitals, emergency access healthcare facilities, and ambulatory surgery clinics are examples of medical facilities. It should be noted that the notice and consent requirements do not apply to the following supplementary services, for which the restriction on balance billing remains in effect:

  • Items and services relating to emergency medicine, anesthesia, pathology, radiology, and neonatology
  • Assistant surgeons, hospitalists, and intensivists supply products and services
  • Diagnostic services, such as radiography and laboratory testing
  • Products and services are offered by a nonparticipating provider if no partnering provider is available to supply similar products or products at such locations

Reactions and Legal Action

For months, the sector has been fighting the January compliance deadline. Health insurers and healthcare facilities have asked for a postponement until 2023 as they await the release of major components of the NSA and the conclusion of the public health crisis.

“These safeguards are far from complete,” said executive vice president Stacey Hughes in a statement from the American Hospital Association (AHA).

With time was running out, the American Hospital Association (AHA), the American Medical Association (AMA), hospitals, and professional associations have launched a lawsuit against the federal government to prevent a portion of the surprise billing restriction. The complaint challenges the clause in the September proposed rule that the IDR procedure places disproportionate priority on the qualifying payment amount (QPA) as a deciding element in the arbitration proceedings, favoring payers and harming providers.

The complaint claims that Congress did not intend for one criterion to be weighted more highly than others, and it demands a fair issue resolution mechanism.

Surprise Billing: Interim final rule

The Departments of Health and Human Services (HHS), Labor, and the Treasury (collectively, the Departments), along with the Office of Personnel Management (OPM), issued an interim final rule with a consultation process on September 30, 2021, headed “Requirements Related to Surprise Billing; Part II.

This regulation implements Title I (the No Surprises Act) of Division BB of the Consolidated Appropriations Act, 2021, by providing additional safeguards against surprise billing and resulting in significant cost pooling for individuals obtaining healthcare insurance items/services.

It expands the No Surprises Act’s protections against unexpected medical bills, including provisions relating to the individual dispute resolution mechanism, fair and reasonable projections for people without health insurance (or self-pay) individuals, the physician dispute settlement procedure, and enlarged constitutional protections to external audit.

In connection with the publication of this interim final rule, the Departments and OPM developed a website aimed largely at providing basic information concerning No Surprises Act provisions. It will contain a federal gateway via which organizations may seek to become authorized independent conflict resolution bodies and providers and payers can engage in the federal independent dispute resolution mechanism.

The Departments and OPM expect to upload additional material on the federal site over the following several months, including instructions on how to launch an impartial dispute resolution process, and to emphasize certain provisions as they become increasingly relevant to various stakeholders and audiences.

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