The U.S. Departments of Labor, Health and Human Services (HHS), Treasury has issued final rules to clarify the federal process to protect consumers against surprise billing.
The departments announced on Friday that the final rules will make certain medical claims payment processes more transparent for providers and clarify the process for providers and health insurance companies to resolve their disputes.
In July 2021, HHS published interim final rules that included requirements for plans and issuers to give providers and facilities certain information about their billed claims and the payment process. Under these rules, if a plan or issuer changes a provider or facility’s service code used for billing purposes to one of lesser value–which would reduce the payment to the provider or facility–the plan or issuer must now provide additional information when submitting an initial payment or a notice of denial of payment for items and services covered by the No Surprises Act.
The departments said that the increased transparency will help providers, facilities, and air ambulance providers take part in more meaningful open negotiations with health plans and will help inform the offers they submit to certified independent entities to resolve claim disputes.
The rules also finalize some aspects of the arbitration process afforded by the No Surprises Act:
- Establishes an Independent Dispute Resolution (IDR) process to determine the total payment amount for out-of-network health care services
- Issues guidance for certified IDR entities on how to make payment determinations and instructs these entities that they must provide additional information and rationale in their written decisions
The final rules also address certain provisions of the July 2021 and October 2021 interim final rules that relate to the operation of the federal IDR process and revise certain provisions in light of two recent federal court decisions in challenges filed by the Texas Medical Association and LifeNet Inc.
In addition to issuing the final rules, the departments released a fact sheet and Frequently Asked Questions Part 55 with guidance on implementing the requirements of the No Surprises Act, including those related to surprise billing protections, open negotiation, and the federal IDR process.