Despite a two-year-old ban on surprise medical billing, insurers and providers are struggling to resolve unpaid claims. In this Axios article, McDermott+Consulting’s Jeffrey Davis offers perspective on the state of the claims resolution process.
The No Surprises Act (NSA) provides federal protections against surprise billing with respect to emergency services, non-emergency items or services furnished by out-of-network providers at certain in-network healthcare facilities, and air ambulance services furnished by out-of-network providers of air ambulance services. The NSA also establishes that certain federal agencies publish information quarterly about the Federal IDR process. The first such report, Initial Report on the Independent Dispute Resolution (IDR) Process April 15 – September 30, 2022, offers insight into dispute volume, interaction of the Federal IDR process with the claims procedure rules and problems with botched claims.
The US healthcare system is entering the third year of a public health emergency due to COVID-19, and the challenges and enduring pressures of the pandemic will require US Congress and the Biden administration to consider new response strategies. But other health policy priorities also will garner attention. As we start a new year and new congressional session, McDermott+Consulting examines the health policy priorities and key initiatives likely to dominate the agenda in 2022.
The Biden administration is giving insurers more time to follow the insurer price transparency rule and the ban on surprise billing. Federal regulators will delay enforcement of machine-readable file provider rates until July 1, rather than the start of 2022. In this article published in Modern Healthcare, McDermott Partner Kate McDonald noted that the initial timeline was “very aggressive.”
The US Departments of Health and Human Services, Treasury and Labor, and the Office of Personnel Management issued an Interim Final Rule with comment implementing portions of the No Surprises Act, legislation enacted in December 2020 that bars surprise billing beginning January 1, 2022. Under the law, payers and providers (including hospitals, facilities, individual practitioners and air ambulance providers) are prohibited from billing patients more than in-network cost-sharing amounts in emergency and non-emergency circumstances. This IFR establishes regulations defining the payment methodology. The regulation proposes the methodology payers must use to determine cost sharing; the information payers must share with out-of-network providers; the process for submitting and receiving consumer complaints; and the format and details of the notice and consent requirements.
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