July 01, 2021

Federal Regulations Implement Ban on “Surprise Medical Billing”

The U.S. Department of Health and Human Services (HHS), the U.S. Department of Labor and the U.S. Department of the Treasury, along with the Office of Personnel Management, have released the first of several interim final rules to implement the No Surprises Act.

These interim final rules with comment period (IFC) will implement the act’s patient protections against “surprise billing” and “excessive cost sharing” related to emergency services and non-emergency services received in in-network facilities.

The No Surprises Act was part of the Consolidated Appropriations Act, 2021 and is scheduled to take effect on Jan. 1, 2022. The law represents a significant step forward for patients and providers.

This first particular rule addresses the law’s requirements related to patient cost sharing for emergency services, air ambulance services provided by out-of-network providers and non-emergency services provided by out-of-network providers at in-network facilities in certain circumstances.

In addition, this IFC provides detailed information on the methodology for calculating the “qualifying payment amount” (QPA). In recent comments to HHS Secretary Becerra, the American College of Radiology® (ACR®) provided input on calculation of the QPA to ensure fairness to healthcare providers.

The IFC does not address the ACR-supported independent dispute resolution process designed to allow providers and insurers an avenue to resolve disputes over out-of-network rates. However, this process is mandated by law and will be addressed in a future rule.

The ACR will conduct a thorough review of the IFC and will provide a detailed summary in the coming days. The Centers for Medicare and Medicaid Services posted a fact sheet on its website.