Most surprise medical bills will end under a new rule

The interim final rule kicks off the process of filling in the No Surprises Act, a controversial and long-delayed bill passed by Congress in December and which former President Donald Trump enacted after much pressure from insurers and carriers. suppliers. Subject to a 60-day comment period, the rule is the first of several that the Biden administration will deploy to implement the law.

Under the rule, patients would only be responsible for their network cost sharing for emergencies and certain non-emergency situations when they cannot choose networked providers.

The regulation, which applies to those with insurance plans based on employment and individual market, also covers non-urgent care provided by non-network providers in network facilities, such as an anesthesiologist. off-network working with a network surgeon or an off-network radiologist reading an x-ray ordered by a network doctor.

It applies to air ambulance services provided by non-network providers, but ground ambulance services are not covered.

If a patient chooses to see off-network providers, they will be prohibited from billing the patient the balance unless they provide notice of their network status and an estimate of charges, usually 72 hours in advance. . The patient should also consent to receive out-of-network care which may cost them more. The rule provides a template that providers can use.

“No patient should forgo care for fear of surprise billing,” said Xavier Becerra, Secretary of Health and Social Services, adding that after the Affordable Care Act, this law will make a major difference in the lives of millions of Americans. “Health insurance should provide patients with the peace of mind that they will not be faced with unforeseen costs.”
Surprise medical bills, which can run into the millions each year, are a major concern for many patients. Two in three adults say they are worried about unforeseen expenses, according to the Kaiser Family Foundation.
According to the foundation, around 1 in 5 emergency claims and 1 in 6 hospitalizations in the network include at least one non-network bill. They can total hundreds or thousands of dollars.

Who pays the rest of the bill

To deal with the rest of the bill, the No Surprises Act requires insurers and providers to go through negotiation or an independent dispute resolution process. The arbitrator would be required to take into account the network median rate, past contracts, complexity of services, provider training and other factors. There would be no minimum payment threshold to enter arbitration.

The rule further defines the median rate in the network, which is the key to what patients will need for care and will serve as the basis for the adjudication process. Using the median rate rather than the average mitigates the influence of high-priced specialists, typically backed by private equity firms, which generate many surprise bills, said Loren Adler, associate director of USC- Brookings Schaeffer Initiative for Health Policy.
Protecting patients from surprise billing has received broad bipartisan support in Congress, but passing legislation to this effect has encountered many obstacles. Despite attempts by lawmakers to appease all parties, the law has drawn criticism from insurers and providers.

Insurers have advocated basing payments on locally negotiated rates, not arbitration. Hospitals have raised concerns about a number of provisions, including holding hospitals accountable for physician billing and payments, among others. Doctors said the law would interfere with the practices of doctors and small offices might not have the resources to participate in arbitration.

The Biden administration will address arbitration and other provisions in subsequent rules. The arbitration process was a controversial and less defined part of the law, and industry representatives are believed to seek to influence the rule.

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