AAHAM Q4 '21

More documents

Recommendations

Info

Preparing for the No Surprises Act: What you need to know now on the new surprise billing law By: Jennifer Boese, (CliftonLarsonAllen, LLP) In early 2019 we wrote a CLA blog on the issue of surprise billing where said we thought there was a better than likely chance something would be enacted in the 116th Congress (2019-2020). Flash forward to 2020 and no one would have expected a global pandemic whose dynamics would lead to enactment of the No Surprises Act under the Consolidated Appropriations Act of 20<strong>21</strong> (Public Law 116- 260). While the years-long legislative debate is over (for now), the regulatory efforts of deciphering and implementing the law are underway. The new policies take effect on January 1, 2022. That is right around the corner and a trio of agencies released multiple implementation regulations. Here’s what you need to know. Issue Surprise bills stem from when a patient seeks medical care at a hospital, free-standing emergency department or from providers he/she believes are innetwork only to receive a “surprise” bill for the balance (i.e.: balance billing) of the cost because somewhere along the line a provider was out-ofnetwork. In these situations, the patient is left with a surprise bill. This can frequently happen in emergency situations but in non-emergencies as well. The No Surprises Act addresses both situations and will impact health care providers (including air ambulances), insurers (individual, group, and selffunded/sponsored) and patients. Emergencies In emergency care situations a health insurer must cover the patient as in-network regardless of whether the facility or provider(s) are participating providers in the patient’s insurance plan. The requirement to treat as in-network during emergencies extends to other hospital departments that are used and services provided after the patient is stabilized unless certain criteria can be met. Emergency facilities include hospitals and freestanding emergency departments. Providers include physic- ians or other health care providers acting within their scope of practice. Emergency services include medical screening and other ancillary services used to evaluate and treat the patient. Air ambulances are also covered. Generally, the provider or facility is prohibited from “balance billing” the patient for the remainder of the uncovered amount during the emergency. In some cases, the facility/provider may be allowed to balance bill and use out-of-network cost-sharing after a patient has been stabilized. However, this is available only if a series of requirements (with many underlying criteria) are met. 8 • The patient can travel using nonmedical and nonemergency transportation • Specific notice and consent criteria are met • A patient is able to receive information and give an informed consent In emergency situations, the insurer is prohibited from using prior authorization or waiting periods and patients are to be treated as if they are covered innetwork (assuming their insurance covers any emergency service) by the group or individual health plan for co-pays or cost-sharing. There are also specific requirements for how insurers determine any costsharing for patients in these situations. The cost-sharing amount will be governed by any state-mandated rates that apply, a state all-payor model rate, or the median in-network rate under the plan for like services by a similar provider in the same geographic region provided on January 31, 2019. This latter option is called the “qualifying payment amount” (QPA). The amount used for patient cost-sharing is based off whichever one of these three options is applicable and is referred to as the “recognized amount.” With respect to payment to providers, an insurer
either sends a notice of denial or a payment to the respective facility/providers within 30 days. A policy in the regulations that providers will like is that insurers may not deny coverage of certain services provided in the emergency department by determining whether an episode of care involves an emergency medical condition based solely on final diagnosis codes or automatically deny coverage based on a list of diagnosis codes initially, without regard to the individual’s presenting symptoms or any additional review. The provider may accept the insurer’s payment or may begin a 30-day negotiation period. If no payment resolution can be reached during those 30 days, the parties may initiate a new independent dispute resolution process. Non-Emergencies In non-emergency situations, unless notice and consent are given, the patient is also held harmless from out-of-network bills when at an in-network facility. A health care facility in a non-emergency situation includes a hospital, hospital outpatient department, critical access hospital or an ambulatory surgical center and the ban on surprise billing would include those that provide items or services at or to those. A few of the criteria for notice and consent in these non-emergency situations are: 1. Notice and consent are provided to the patient at least 72 hours prior (if scheduled within at least 72 hours) or at time of service if less than 72 hours, but not less than three hours 2. The notice and consent form clearly states consent is optional or the patient may seek care from a participating provider. The form is signed, maintained by the provider and given to the patient (email or mail, patient preference) 3. Information on prior authorization or other care management requirements 4. A good faith estimate of the cost is given 5. A list of in-network providers is given 9 Notice & Consent With respect to both emergency and non-emergency situations, it is important to note that the No Surprises Act and regulations specifically exclude certain services and items from the notice and consent procedures altogether. In other words, patients may not provide consent nor may certain providers request consent (to balance bill) under various circumstances for the following ancillary services and situations: • Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether or not provided by a physician or non-physician practitioner, and items and services provided by assistant surgeons, hospitalists, and intensivists, • Diagnostic services (including radiology and laboratory services), • Items and services provided by other specialty practitioners, as provided by HHS, • Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility, • Unforeseen medical needs arising at the time of the service Independent Dispute Resolution (IDR) If there are disputes between the health care provider and insurer related to reimbursement, a newly created IDR process may be utilized. There are various timelines that must be followed during this process. If after 30 days of open negotiation the two sides cannot come to a resolution, either side may initiate the IDR process. Once the IDR entity is selected each entity submits their best and final offer. The provider and insurer may submit additional information to support its offer. The arbitrator does not have the discretion to change either offer, so will select one or the other as is. However, in its deliberations, the law allows arbitrator may consider other factors, such as the level of training, experience, quality and outcomes, market share held in that geographic region, patient acuity, complexity of services, teaching status, case mix, and scope of services among others. The arbitrator may
Page 2 and 3: IN THIS ISSUE President’s Message
Page 4 and 5: 3 Updates from ABC for Health; Nove
Page 6 and 7: MEASURING THE COST OF DENIALS & THE
Page 8 and 9: 6 Bottom line: top-performing organ
Page 12 and 13: 10 not consider a provider’s char
Page 14 and 15: A A H A M CERTIFICATIONS AAHAM Cert
Page 16 and 17: Healthcare Staff Management in the

AAHAM Q4 &#039;21

Create successful ePaper yourself

Delete template?

Save as template?

AAHAM Q4 '21