Despite objections from the American College of Radiology® (ACR®) and others in the medical provider community to an egregious regulation imposed by the Biden Administration to implement the No Surprises Act, the regulation went into effect Jan. 1. Members who provide out-of-network patient care and/or care to uninsured or self-pay patients must be aware of their obligations under the ACR-supported law and the objectionable implementation regulation.
The No Surprises Act is intended to protect patients from surprise medical bills when they receive out-of-network care in emergency settings and non-emergency services performed at in-network facilities. Patients are only responsible for cost-sharing amounts that would be their responsibility if care had been provided in-network. The U.S. Departments of Health and Human Services (HHS), Labor and Treasury decided unilaterally to base these amounts on median in-network rates as calculated by the Qualified Payment Amount (QPA) methodology outlined in regulations released in July.
ACR members who provide out-of-network patient care may no longer bill patients for out-of-network emergency care or non-emergency care provided at in-network facilities for amounts higher than the patient’s in-network cost sharing amount. Providers are able to use an independent dispute resolution (IDR) process to negotiate a higher reimbursement amount from the payer. The law as written intends for several factors, including the QPA, experience/training, quality metrics, market share, patient complexity and scope of services provided at a facility to be considered equally in the process.
The ACR, along with the American Society of Anesthesiologists and the American College of Emergency Physicians filed a lawsuit in December against the HHS, Labor and Treasury, charging that their interim final rule detailing the IDR process goes against the statutory intent by instructing the IDR entities to make the QPA the primary determining factor rather than considering it equally among other factors in determining payment. The medical associations maintain that this interpretation sets an artificially low payment benchmark for all care, both in network and out of network.
Another provision of the law that is now in effect is the requirement that providers give patients a good faith estimate of the cost of services provided to uninsured and self-pay patients in advance of the patient’s appointment. If the actual charges by a particular provider or facility exceed the good faith estimate amount by more than $400, the patient is entitled to dispute the charges under an arbitration process.
Background information and resources are available to members on the ACR website. In addition, the American Medical Association has made available a detailed toolkit for physicians outlining the provisions of the No Surprises Act and providers’ obligations under the law.
For questions regarding implementation of the No Surprises Act, please contact Katie Keysor, ACR Senior Director of Economic Policy.