Surprise billing protections take effect next year: Tips to prepare now

In late 2020, Congress passed the No Surprises Act to protect patients from surprise billing. The legislation, which takes effect next year, will require providers to revamp several revenue cycle processes. 

In a Feb. 25 webinar, sponsored by Xtend Healthcare and hosted by Becker's Hospital Review, two industry experts discussed the regulatory requirements outlined in the law and how physicians and hospitals can start preparing for new billing and payment processes.

The presenters were:

  • Linda Corley, vice president of compliance and quality assurance, Xtend Healthcare
  • Mike Morris, president and CEO, Xtend Healthcare

Five key takeaways from the webinar:

1. The federal law prohibits arbiters from considering government insurance rates. During the independent dispute resolution process, also known as arbitration, the entity overseeing the dispute is prohibited from considering the payment rate from government insurance plans like Medicare, Medicaid and Tricare, which are typically lower than commercial plan reimbursement rates. This is a small win for providers because it may mean higher reimbursement, Ms. Corley said.

2. In states with balance-billing laws, the federal law defers to state rules on payment amounts. Currently, 17 states have laws providing comprehensive balance- billing protections, and 13 have partial surprise-billing protections, Ms. Corley said. For states with laws already in place, the federal regulation defers to the state rules on establishing payment amounts, even if the state has a payment standard.  

3. Consent waivers have many parameters. The legislation allows certain out-of-network providers to seek written consent from patients that will allow them to balance bill. However, this is banned in certain specialties, including anesthesiology, radiology and neonatology. It is also prohibited for services provided by assistant surgeons, hospitalists and intensivists, and HHS said it may add additional services to this list, Ms. Corley said. 

4. The party that loses the arbitration decision must pay the fees. The losing party in arbitration is responsible for all fees associated with the independent dispute resolution process. "I think Congress felt this would be an incentive against seeking arbitration for weaker cases," Ms. Corley said. 

5. Expect more guidance and clarification from HHS in the coming months. The No Surprises Act was included in an omnibus spending bill in the last session of Congress before a recess, Mr. Morris said. As a result, this means that there are many details still to come, including how providers should calculate a qualifying payment amount to be used in the dispute resolution process and how independent dispute resolution entities will be certified. "Ultimately, expect a lot of changes and clarifications to come down the pike to help better craft what this legislation will mean for us as an industry," Mr. Morris said. 

To learn more about the legislation, including the arbitration process, consent waiver parameters and frequently asked questions, listen to the full webinar here.

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