HHS Announces Surprise Medical Billing Rule

Today, the Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.

Among other provisions, today’s interim final rule:

  • Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
  • Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
  • Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
  • Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

The regulations issued today will take effect for health care providers and facilities January 1, 2022. For group health plans, health insurance issuers, and FEHB Program carriers, the provisions will take effect for plan, policy, or contract years beginning on or after January 1, 2022.

Fact sheets on this interim final rule can be found here and here.

The interim final rule with comment period can be accessed here.

National Surprise Medical Billing proposal is an improvement.

CHICAGO – The American Society of Anesthesiologists (ASA) is pleased that a number of ASA’s priorities were addressed in the most recent COVID-19 stimulus bill; some improvements to the final surprise medical bill provisions and partial relief from the previous draconian Medicare cuts scheduled for January 1, 2021.

“I believe our specialty will be better off in 2021 than was initially anticipated,” said ASA President Beverly K. Philip, M.D., FACA, FASA. “However, the surprise medical bill provisions and the Medicare payment cut relief remain far less than ideal. ASA remains committed to working vigorously on these issues, to ensure that frontline anesthesiologists are in no way disadvantaged.” 

Regarding Surprise Medical Bills, ASA worked with other physician stakeholders to secure important additional improvements into the bill that were not included in the December 11, “No Surprises Act” draft proposal, including:

  • An explicit prohibition on health insurance companies presenting artificially low Medicare, Medicaid and public payer rates to an arbiter as part of the independent dispute resolution (IDR) system.
  • Elimination of unreasonable timelines and other requirements related to patient notification and billing requirements.
  • Enhanced physician access to the IDR process by adding clarity to the “90 days cooling-off period” 

The language in this bill are improvements to earlier proposals, which included aggressive government rate-setting, administrative burdens on small and medium sized practices,  and inaccessible and insurer-friendly dispute resolution processes.