News: CMS issues surprise billing interim final rule

CDI Strategies - Volume 15, Issue 45

The CMS released its interim final rule on surprise medical billing, introducing a process whereby payers and providers could negotiate payments for “out-of-network” billing. Each side, however, gave the long-awaited provisions decidedly different receptions.

“In short: Hospitals Hate it. Payers are delighted,” HealthLeaders reported.

The key point of contention—the independent dispute resolution process –presumes that the payer's out-of-network reimbursement is the starting point for negotiations. Then, the disputing stakeholders have a 30-day "open negotiation" to determine a payment. If they're still at loggerheads, they can move to a dispute resolution process, which is conducted by a jointly selected "certified independent dispute resolution entity" that's been authorized by CMS.

CMS says the dispute resolution process "will take patients out of the middle of payment disputes, provides a transparent process to settle out-of-network rates between providers and payers, and outlines requirements for healthcare cost estimates for uninsured (or self-pay) individuals."

CMS Administrator Chiquita Brooks-LaSure said the final rule requires "healthcare providers and healthcare facilities to provide uninsured patients with clear, understandable estimates of the charges they can expect for their scheduled healthcare services."

Stacey Hughes, executive vice president of the American Hospital Association, called the rule "a windfall for insurers."

Federation of American Hospitals President and CEO Chip Kahn called the final rule "a total miscue" that goes against the intent of Congress when it passed the law.

Matt Eyles, president and CEO of America's Health Insurance Plans, said the final rule "signals a strong commitment to consumer affordability and lower healthcare spending through an independent dispute resolution process that should encourage more providers to join health plan networks."

Justine Handelman, senior vice president of policy and representation for the Blue Cross Blue Shield Association, called the IFR "a win for patients and a step toward building a more affordable and equitable healthcare system.

The IFR is also getting panned by the American Medical Association, which called it "a surprise gift to the insurance industry," HealthLeaders reported.

Like the hospital associations, the AMA says the IFR "ignores congressional intent and flies in the face of the Biden Administration's stated concerns about consolidation in the health care marketplace."

Thursday's final rule is the third in a series of implementations of the No Surprises Act put forward by the Departments of Health and Human Services, Labor, Treasury and the Office of Personnel Management.  

In September, policy makers issued a rule to help collect data on the air ambulance provider industry, and in July issued a rule on consumer protections against surprise billing. All of the rules take effect on January 1, 2022.

Editor’s note: This article was originally published by HealthLeaders.

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