Five Things Vendors Need to Know About the New No Surprises Interim Definitive Rule | Cozen O’Connor

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On Thursday, September 30, 2021, the US Department of Health and Human Services (“HHS”), the Department of Labor and Treasury released a preliminary final regulation (“Rule”) that covers most of the regulatory framework of the federal “No Surprises Act “Completed (” Law “). The law largely prohibits balance accounting for patients receiving emergency services or hospital-based provider services (in an on-network facility) outside the network. This is the second part of the agencies’ rulings under the law. The first part was published in July 2021. This second part is mainly concerned with the Independent Dispute Resolution (“IDR”) procedure, which determines the “reasonable off-grid tariff” to be paid by the health insurance provider to the provider for a specific person and emergency or hospital care part of the provider’s price transparency requirements according to the law.

Below are five things healthcare providers should understand about the new rule.

  • The rule is final and its provisions will take effect on January 1, 2022.

Although there is a 60-day public comment period on the rule, which begins when the rule is published in the federal register, the rule technically takes effect immediately after such publication, with providers and plans being obliged to comply with their provisions on January 1, 2022 , and then.

Providers can initiate an open negotiation period of 30 business days to determine the applicable off-line payment rate, starting on the day the payer pays or declines the off-line claim. If an agreement cannot be reached, either the vendor or the plan can initiate the IDR process within 4 working days of the end of the open negotiation period and the parties must select a certified IDR entity within 3 working days of initiating the IDR process . Disputes over claims between the same provider or groups of providers (with the same TIN or NPI) and the same plan for the same or similar services may be aggregated for IDR purposes in 90-day increments from the date of service.

  • It is assumed that the contracted median rate of the plan is the appropriate out-of-network rate in the IDR process

In perhaps the most controversial aspect of the rule, the parties have the burden of “clearly” [demonstrate] that the [plan’s median contracted rate] The IDR process involves a “baseball-style” arbitration process in which both sides submit an offer to settle the dispute. The IDR certified entity must select the offer that most closely approximates the contracted median rate of the plan (referred to as the “qualifying payment amount” or “QPA”) unless a party fulfills the burden with “credible evidence” that the QPA differs significantly from the reasonable rate outside the network.

  • There are certain factors the IDR company must consider and certain factors it may not be able to consider in determining the appropriate out-of-network rate.

When selecting the offer, the certified IDR body must consider the following:

  • The qualifying payment amount (s) for the relevant year for the same or a similar item or service.
  • Information requested by the certified IDR about the offers themselves.
  • Additional information submitted by a party about:
  • The level of training, experience, and quality and outcome measurements of the provider or facility that are provided.
  • The level of training, experience, and quality and outcome measurements of the provider or facility that are provided.
  • The level of training, experience, and quality and outcome measurements of the provider or facility that are provided.
  • The level of training, experience, and quality and outcome measurements of the provider or facility that are provided.
  • The level of training, experience, and quality and outcome measurements of the provider or facility that are provided.

When selecting the offer, the certified IDR body must not take the following into account:

  • Usual and customary fees (including payment or reimbursement rates relative to customary and customary fees).
  • The amount that would have been billed by the provider for the service had the No Surprises Act not come into effect.
  • The rate of compensation or reimbursement for supplier-provided items and services payable by a public payer, Medicare, the Medicaid program, CHIP, TRICARE, or demonstration projects under Section 1115 of the Social Security Act.
  • Providers must provide good faith estimates of the cost of planned items or services of $ 400 to uninsured (or self-paying) individuals starting January 1, 2021

In August 2021, HHS announced that it would postpone enforcing the requirement that providers and facilities have good faith valued information for those enrolled on a health plan for planned items or services who wish to claim reimbursement for such a benefit plan, until HHS publishes regulatory guidelines specific to providing good faith estimates to these individuals. However, the rule continues to require that providers provide uninsured and self-paying individuals / patients such estimates in good faith in writing from 1. 3 to 10 days in advance) or within 3 days of the patient’s request. The provider planning the service or receiving the request must also contact “co-providers” who may be involved in the delivery of the “primary” planned item or service to include the co-provider fee in the estimate to be included.

If the vendor’s invoice amount for the estimated service exceeds the good faith estimate by more than $ 400, the individual may request that the amount payable be settled by a selected dispute resolution agency (SDR) for within 120 days of receiving the invoice such services. In order to receive an amount under the SDR process that exceeds the good faith estimate for the services, the provider must “provide credible information to demonstrate that the difference between the fee billed and the expected fee for the item or service in the good faith estimate reflects the cost of a medically necessary item or service and is based on unforeseen circumstances that the provider in good faith could not foresee at the time the estimate was made. “

The rule contains a significant amount of operational details that affected providers must define in the next calendar quarter in order to be compliant with the rule by the time the operational provisions come into force.


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