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New Additions to Surprise Billing Rules

Medical Billing

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A new surprise billing rule that “establishes dispute resolution process for patients, providers, and plans,” was released recently in September of this year. The Department of Health and Human Services released an addition to the rules that outlines the “No Surprises Act.” The No Surprises Act “prohibits balance billing in the case of surprise medical bills — those for non-emergency services furnished by out-of-network providers during a visit by the patient at an in-network facility — unless the law’s notice and consent requirements are met,” (National Law Review, Cummings). This act was first introduced as a part of the Consolidated Appropriations Act, which was enacted in December of 2020.

“A surprise bill is an unexpected bill from a health care provider or facility. This can happen when a person with health insurance unknowingly gets medical care from a provider, facility, or provider of air ambulance services outside their health plan’s network. Surprise billing happens in both emergency and non-emergency care settings,” (CMS, 2021). In an emergency, the patient will be treated by the facility nearest them; this can result in care being performed by those not in-network with the patient’s insurance. In non-emergency cases, patients may have chosen a facility and/or physician that is in-network with their insurance, however, someone behind the scenes of their care, for example a radiologist or an anesthesiologist, may not be in-network. This can cause an outstanding bill for the patient that they were not expecting, which is where this No Surprises Act comes into play.

This new rule continues to protect patients against surprise medical bills by following through with out-of-pocket limits, and requiring patient consent before performing any medical procedures or examinations. Along with following previous procedures and ideals for this rule, MDHHS has included a new process and guidelines for independent dispute resolution (IDR). This allows patients to dispute a surprise medical bill when the care provided was not discussed and approved beforehand. Patients will also be granted good faith estimates for uninsured (or self-pay) individuals. Patient-provider dispute resolution processes are outlined in this new rule, allowing patients to discuss these matters directly with their medical provider with expanded rights to external review. The process that agencies will use to evaluate the IDR disputes are outlined as well. IDR will be implemented starting at the first of the year in 2022. The Federal Register released the second interim final rule on their website.

Please visit the new CMS Surprise Billing Page for all of the latest updates. “The Departments and OPM intend to post additional information over the next several months, including information about how to initiate an independent dispute resolution process in the federal portal, and plan to highlight different provisions as they become more relevant to different stakeholders and audiences,” (CMS, 2021).


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