People continue to receive “surprise medical bills” for being unknowingly treated providers outside their health insurance network even after Congress passed a law prohibiting it.
On Friday, the Department of Labor, the Department of the Treasury and the Department of Health and Human Services took steps that are expected to prevent consumers from getting them at all. It issued final rules regarding standards related to the provider-payer arbitration process that is key to implementing the Law without surprises.
“The final rules will make certain medical claims payment processes more transparent for providers and clarify the process for providers and health insurance companies to resolve their disputes,” the Department of Labor said in a news release.
These rules apply to group health plans and health insurance issuers offering group or individual health insurance coverage.
“The increased transparency required under these final rules will help providers, facilities, and air ambulance providers engage in more meaningful open negotiations with plans and issuers and will help inform the offers they submit to certified independent permitting entities.” of claims disputes,” the DOL said.
The finalized rules are an updated version of the July and October 2021 interim rule sets and take into account relevant provisions from federal court decisions in challenges from Texas Medical Association and from an air ambulance provider LifeNet Inc. In both cases, the judges ruled this parts of the arbitration process described in the surprise billing rules violate the Administrative Procedure Act, which requires a public comment period when the government issues new rulings.
In response to MedCity News’ inquiry about the recently finalized rules, the TMA said, “We are reviewing the rule and considering next steps.”
The government has finalized an arbitration process, known as the independent dispute resolution process or federal IDR process, to determine the total payment amount for out-of-network health services for which the law prohibits surprise billing. The final rules also include guidance for certified IDR entities on how to determine payments and instruct those entities that they must provide additional information and rationale in their written decisions.
For example, if the insurer “downcodes” or changes a billing code that would reduce how much the provider pays for a service, then the insurer must issue a statement indicating that the billing code has been changed and explain the rationale for the change.
In November, the departments temporary rules issued related to prescription drugs and health care costs. The rules require group health plans and issuers to submit information on the most prescribed and most expensive drugs and premium information, including average monthly premiums paid by employers and employees.
According to the Centers for Medicare and Medicaid Services, “together, they lay the groundwork to provide consumers with protection against surprise billing.”
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