Government publishes final rules to avoid surprise medical bills

People continue to receive ‘surprise medical bills’ for being unknowingly treated by providers outside of their health insurance network even after Congress passed legislation banning this.

On Friday, the Department of Labor, Department of Treasury and Department of Health and Human Services took action that should prevent consumers from receiving them. This issued final rules regarding standards for the arbitration process between providers and payers that is essential to the implementation of the law without surprise.

“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 disputes,” the Department of Labor said in a news release.

These rules apply to group health insurance plans and to health insurers offering group or individual health insurance coverage.

“The increased transparency required under these final rules will help air ambulance providers, facilities and providers engage in more meaningful, open negotiations with plans and issuers and help inform the offers they submit. to certified independent entities to resolve claim disputes,” the DOL said.

The finalized rules are an updated version of the July and October interim rule sets from 2021, and take into account the relevant provisions of Federal Court decisions in challenges of Texas Medical Association and air ambulance provider LifeNet Inc. In both cases, the judges ruled that parts of the arbitration process outlined in the surprise billing rules violated the Administrative Procedure Act which requires a public comment period when the government makes new decisions.

In response to a MedCity News inquiry into the recently finalized rules, the TMA said, “We are reviewing the rule and considering next steps.”

The government finalized the arbitration process known as the Independent Dispute Resolution Process, or Federal IDR Process, to determine the total amount of payment for out-of-network health services for which surprise billing is prohibited by law. The final rules also include guidance for certified IDR entities on how to determine payouts and direct those entities to provide additional information and justification in their written decisions.

For instance, if an insurer “downcodes” or changes a billing code that would reduce the amount paid to a provider for a service, then the insurer must issue a statement that the billing code has been changed and explain the reason for the change .

In November, the departments issued interim rules related to prescription drugs and healthcare costs. The rules require group health plans and issuers to submit information on the most dispensed and most expensive drugs and information on premiums, including the average monthly premiums paid by employers and employees.

According to the Centers for Medicare and Medicaid Services, “together, they lay the foundation for providing consumers with surprise billing protection.”

Photo: KLH49, Getty Images

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