CMS unveils surprise-billing rule: 10 things to know

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CMS unveiled July 2 the first in a series of rules aimed at shielding patients from surprise billing. The interim final rule addresses several provisions in the No Surprises Act passed by Congress last year.

Most provisions outlined in the proposed rule will not take effect until Jan. 1, 2022. 

Ten things to know:

1. Bans surprise billing for emergency services. The interim final rule bans surprise billing for emergency services, regardless of where they are provided. Providers are required to bill emergency services on an in-network basis without prior authorization.

2. Bans high out-of-network cost-sharing for emergency and nonemergency services. CMS proposed that patient cost-sharing, including coinsurance and deductibles, be based on in-network provider rates. This means that cost-sharing can't be higher than if the services were provided by an in-network physician. 

3. Bans surprise billing for ancillary services and any "others." The interim final rule prohibits out-of-network charges for ancillary care in in-network facilities in all instances. This includes anesthesiology services. CMS said that it also includes a ban on any other out-of-network charges to patients without notice. 

4. Interim payment or notice of denial from insurers. The interim final rule would require health plans to make an initial payment or issue a notice of denial to providers in 30 days after it receives a clean claim. 

5. Consent process to waive balance-billing protections. The law allows patients to waive their balance-billing protections and consent to out-of-network charges. The rule directs the departments to establish a process to obtain patient consent for balance billing. Providers can't use this for emergency services or some ancillary services.

6. Providers must disclose balance-billing protections. Providers will be required to post publicly to inform patients about their surprise-billing protections.

7. Qualifying payment amount. CMS defined the qualifying payment amount, which will calculate patient cost-sharing and be used by an arbiter in the independent dispute resolution process, as the issuer's median in-network rate for 2019 trended forward. The rule addresses several factors that will determine how the rates are set, including the type of contract, insurance market, geographic region and rates for same or similar services. 

8. Complaint process. Through the proposed rule, CMS will establish a process for which patients and others can submit complaints about violations of the balance-billing requirements. 

9. Arbitration process. The first interim rule doesn't discuss the dispute resolution process. 

10. Comment period. Providers will have 60 days to comment on the interim final rule. 

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