Agencies release a final rule for No Surprises Act
The update includes guidance on how entities conducting independent reviews of disputes about charges can resolve differences.
Three federal agencies have released a final rule updating several key provisions of the No Surprises Act.
The No Surprises Act establishes patient protections against surprise medical bills and includes several transparency provisions.
The updated final rule, jointly released by the departments of Health and Human Services, Labor and Treasury, includes guidance on how entities conducting independent reviews of disputes about charges can resolve differences.
Information on this recent release of requirements related to surprise billing can be found here. The text of the final rule itself, available here, contains “certain disclosure requirements relating to information that group health plans, and health insurance issuers offering group or individual health insurance coverage, must share about the qualifying payment amount (QPA) under the interim final rules issued in July 2021.”
The agencies released these “Requirements Related to Surprise Billing: Final Rules” to clarify certain requirements under the July 2021 interim final rules “relating to information that group health plans and health insurance issuers offering group or individual health insurance coverage must share about the qualifying payment amount (QPA),” according to a fact sheet issued with the rules.
The just-released final rule will take effect 60 days after they are published in The Federal Register.
The July 2021 interim rules require health plans to disclose the QPA for each item or service to providers, facilities and air ambulance service providers, with each initial payment or notice of denial of payment to ensure that providers “have the information they need to engage in meaningful open negotiations.”
The new final rule adds a definition of the term “downcode” – the change of a service code by a plan or insurer that results in a lower qualified payment – and require that plans and issuers disclose additional information if they downcode.
The final rule also establishes:
- A federal independent resolution process portal, now live, which can receive requests for resolution of payment disputes for certain out-of-network healthcare items and services;
- Federal independent dispute resolution process guidance for certified IDR entities,a document that directs certified IDR entities with an overview of the IDR process and their responsibilities as part of the process; and
- Federal independent dispute resolution process guidance for disputing parties,which includes adocument that provides information on how disputing parties engage in open negotiation prior to the federal IDR process, initiate the federal IDR process, select a certified IDR entity and meet the requirements of the federal IDR process.
The Workgroup for Electronic Data Interchange will not be commenting on the independent dispute resolution process because its membership includes both health plans and providers, says Rob Tennant, vice president of federal affairs for WEDI.
“However, we are expecting a regulation to be released at some point outlining the Advanced Explanation of Benefits requirement of the No Surprises Act,” and WEDI will have offer comment at that time. Tennant adds.
Earlier, WEDI raised several concerns about implementing the No Surprises Act, particularly around preparing simple, understandable and accurate price quotes to consumers. WEDI also has noted that challenges will arise when coordinating and communicating accurate estimated costs for consumers for complex cases involving several providers.
In tandem with the new final rule, the Centers for Medicare & Medicaid Services has launched a new webpage with resources and guidance related to the dispute resolution process under the No Surprises Act, including guidance for disputing parties and a walk-through of the federal portal.
That web page includes information on common mistakes and helpful tips; communications; submitting fees; submitting a complete dispute; batching and bundling disputes; and getting help.