Earlier we talked about what surprise medical billing is. Following the journey to the implementation in 2022, the newest update on September 30th outlines new rules related to the banning of surprise medical billing. We will summarize some important points in this week’s post.
Titled “Requirements Related to Surprise Billing: Part II”, this new update expands on the July 13th rules, as well as the September 10th notice of proposed rulemaking. This new part to the rules outlines more details on some of the following:
- Independent dispute resolution
- Good faith estimate requirements for the uninsured
- Patient – provider dispute resolution procedures for the uninsured
- External review provisions of the No Surprises Act
- For Out of Network (OON) providers
- For the purpose of handling disputes to decide on the OON rates after an “unsuccessful open negotiation”
- Open negotiations happen before the independent disputes and are for a length of 30 days
- Only for services for which balance billing was banned for in Part I of the requirements for surprise medical billing, example: emergency services
After open negotiations, if the parties involved do not reach an agreement, then a certified independent dispute resolution entity can be selected jointly. This starts the independent dispute process. The entire process has certain deadlines to meet in this timeframe. For example, payments to the applicable party must be made within 30 business days after the payment determination date. There are also other deadliness associated with responsibilities such as selecting a certified dispute resolution entity. For more details on the timeline, you can view this Centers for Medicare and Medicaid Services (CMS) webpage.
Good faith estimates
- Providers must give a good faith estimate for uninsured individuals of expected charges for their services
- Must include expected charges for each service that is or may be involved. For example, if surgery is the main service, potential charges for anesthesia or tests that may be involved in the procedure must be communicated to the uninsured individual as well
- Services that are not scheduled but may be performed will also need to be in the good faith estimate. Services that are scheduled such as post-op rehabilitation services do not need to be included in the good faith estimate
Patient-Provider Dispute Resolution
- Dispute resolution process between patients and healthcare providers
- Process takes place when patients are billed significantly more than what they were expecting based on the good faith estimates
- This dispute will be allowed if
- There was indeed a good faith estimate
- The dispute is initiated within 120 days of when the patient received the bill
- The charge was “substantially” over the good faith estimate ($400 more)
- Expands and sets standards for determination of external review
- Purpose is to review whether plans are compliant with the rules under the No Surprises Act
For more detailed information on the Part II rules, you can view the full requirements on the CMS website here.
The No Surprises Act will be in effect January 1st, 2022. Ensure your healthcare facility and your staff are aware of the changes and the necessary actions you need to take prior to this date. We, at Americare Network, will also keep up-to-date on new policy changes in the industry. Contact us today to learn more about how we can help healthcare facilities with medical billing needs.