Surprise Billing Rules

Surprise Billing Rules

The No Surprises Act is meant to protect patients from surprise bills and uses an arbitration approach, rather than a benchmark
payment standard, to settle payment disputes between payers and providers in cases of out-of-network care.

On Dec. 15, 2021, we joined with four other national hospital organizations in filing an amicus brief in U.S. District Court in support of a lawsuit by the American Hospital Association and American Medical Association that seeks to block implementation of the No Surprises Act’s independent dispute resolution (IDR) provisions, which will be used to resolve insurer/provider payment disputes in surprise billing situations. Our brief provides supporting information to the Court, and was signed by the Federation of American Hospitals, Association of American Medical Colleges, Catholic Health Association and America’s Essential Hospitals, in addition to CHA.

On Dec. 6, we submitted comments on the second interim final rule that implements the IDR provisions and certain aspects of the good faith estimate requirements of the act. Our comment letter urges the administration to revise the rule’s IDR provisions; delay enforcement and simplify the requirements of the good faith estimates; and modify the rule’s $400 threshold that triggers the option for patients to seek a dispute resolution process with a provider. 

The administration released its first rule on the act in July 2021. Our comments on that rule emphasize the importance of distinguishing between pediatric and adult services and providers in the methodology to calculate the qualifying payment rate that will be used to determine patient cost-sharing obligations and be considered during IDR; recommend ways to ensure that children are appropriately transferred during an emergency to pediatric providers equipped to care for them; and highlight needed refinements to patient notice and consent requirements and oversight of plans’ claims processing to prevent payment delays.

Both rules are immediately effective and generally apply to the insurance plan year that begins Jan. 1, 2022, absent court action on implementation of the IDR provisions.

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