Biden Administration advances new protections against surprise medical bills

The Biden Administration 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, through the Departments of Health and Human Services, Labor, and Treasury, and the Office of Personnel Management. This regulation establishes a procedure to settle out-of-network prices between providers and payers, to keep patients out of the midst of payment disputes. It also lays out the standards for uninsured or self-pay patients’ healthcare expense estimations. A payment-dispute-resolution mechanism for uninsured or self-pay persons is also included in the rule. It also strengthens the external review mechanism, allowing those with job-based or individual health insurance to appeal denials of certain claims. During a news conference on Thursday, Dr. Ellen Montz, deputy administrator and head of the Center for Consumer Information and Insurance Oversight, said that the capacity to settle payment issues will be extremely important for Americans. Uninsured people would have the right to a good faith estimate from a provider or facility regarding the services they plan to get under the new dispute resolution process. Not only would the estimate need to cover the specific treatment, but also any sort of follow-up services that would be provided during the whole episode of care. According to Montz, this assessment is crucial to participating in the dispute settlement process. If a service is provided and the cost is more than expected — $400 or more – the patient can seek arbitration. The plan, according to HHS Assistant Secretary for Legislation Melanie Egorin, will also restrict excessive out-of-network prices.

The rule is the third in a series issued by the Departments of Justice and the Office of Personnel Management to implement the No Surprises Act, a bipartisan consumer protection law that the administration directed HHS to prioritize and implement as part of the Executive Order on Promoting Competition in the American Economy. In addition to regulation on consumer safeguards against unexpected billing released in July, the Departments and OPM adopted a rule in early September to assist gather data on the air-ambulance-provider business. These guidelines will go into effect on January 1, 2022, and will prohibit surprise billing for emergency services and some non-emergency care given by OON providers at in-network institutions, as well as limiting high OON cost-sharing for emergency and non-emergency treatments for patients. The new rule explains how an OON provider or facility’s total payment will be calculated. Independent dispute resolution bodies will be certified by the departments to undertake payment determinations on a rolling basis. Those who want to be certified by January 1, 2022, must submit their applications by November 1. The departments are also issuing Fee Guidance for the Federal Independent Dispute Resolution Process Under the No Surprises Act for Calendar Year 2022. The guideline outlines the costs that certified independent dispute resolution bodies will be permitted to charge in 2022, as well as the administrative fee that parties to a dispute will be required to pay to participate in the process.

When a patient sees an out-of-network physician during an emergency, or when a patient sees an in-network provider but receives care from an out-of-network provider, such as an anesthesiologist, surprise billing happens. When a patient obtains out-of-network care, they may receive the balance of the bill, or the difference between the entire charges and what has been paid, unwittingly. Furthermore, unexpected billing might expose many people to the financial strains of a countrywide epidemic. According to research, 41% of insured people in the United States were shocked by a medical cost in the last two years, and two-thirds of adults are concerned about their capacity to pay an unexpected medical expense. In December 2020, Congress approved the No Surprises Act, prohibiting most surprise out-of-network charging for plan years beginning in 2022. It mandates that insurers use in-network cost-sharing and bans out-of-network providers from balance billing on unexpected medical costs. According to the Kaiser Family Foundation, the statute does not apply to invoices from ambulances, which is significant since an estimated 1.5 million privately insured individuals are transported to an emergency department by ambulance each year and maybe in danger of receiving a surprise medical charge. Despite the fact that the No Surprises Act does not address unexpected ambulance costs, it does mandate the formation of a government advisory group to examine and suggest methods for protecting people from them.

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