Practice Management Alert


Prepare to Comply With These Balance Billing Changes for 2022

Hint: Keep this form on hand for patients who wish to proceed with out-of-network services.

Balance billing has been in the news recently, in part because there is new legislation will affect many providers and patients. Know what obligations are coming down the pike, according to information in a recent interim final rule, which goes into effect Sept. 13, 2021.

“Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs. The Biden-Harris Administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises,” said Xavier Becerra, Secretary of Health and Human Services (HHS).

Once you know what’s coming, you’ll want to start preparing, so you’re ready when the changes go into effect on Jan. 1, 2022.

Hospitals, Air Ambulances Face the Most Changes

A lot of the recent balance billing legislation surrounds emergent care, so hospitals will probably bear the brunt of the changes. The legislation says that emergency care must be billed at in-network rates, without prior authorization, for both facilities, as well as the individuals providing services.

Air ambulances are also facing tighter payment regulation, says Catherine Howden, director of CMS News and Media Group, quoting a 2019 study by the Government Accountability Office (GAO) that found that the median price charged by air ambulances was nearly $40,000, and 70 percent of these transports were considered out of network for patients.

However, individual providers providing services for care that isn’t emergent will have new obligations as well. The interim final rule also says that nonemergency services provided by out-of-network providers must be treated like in-network services, unless the insured individual is provided notice and gives consent, says Lisa A. Lucido at Hall Render, in online analysis of the interim final rule.

This encompasses equipment and devices, as well as services like telemedicine, imaging, laboratory, and pre- and postop — regardless of whether the provider furnishing the services is present at the facility, she says.

Balance Billing Still an Option in Some Circumstances

The rules described here have a pretty broad purview, applying to group health plans, health insurance issuers offering group or individual health insurance coverage, including grandfathered plans, with plan or policy years beginning on or after Jan. 1, 2022. Healthcare providers and facilities (and air ambulance services) will also be held to these rules beginning Jan. 1, 2022.

The federal register says “… balance billing continues to be permitted, unless prohibited by state law or contract, in circumstances where these interim final rules do not apply, such as for non-emergency items or services provided at facilities that are not included within the definition of health care facility in these interim final rules.”

The spirit of the new law is to protect patients from unexpected bills for care they need and receive, but the legislation holds space for patients who may want to pursue care out of network, as long as the provider in question is transparent with the patient ahead of time.

“To reduce burden and facilitate compliance with these disclosure requirements, the Departments are concurrently issuing a model disclosure notice that health care providers, facilities, group health plans, and health insurance issuers may, but are not required to, use to satisfy the disclosure requirements regarding the balance billing protections,” the interim final rule says.

The comment period on the model forms closed Aug. 12.

Patients Can Lodge Complaints

Although the No Surprises Act and this interim final rule involve multiple federal agencies, there will be one central system for patients to lodge complaints with providers who violate the new rules.

Right now, the specifics haven’t yet been fully determined; HHS and the Centers for Medicare & Medicaid Services (CMS) are still deciding the appropriate period for a time limit on complaints. If you, as a stakeholder, have an opinion, please be sure to comment publicly by Sept. 7, 2021.

According to the interim final rule, an agency will respond, with information for the patient about their respective rights, obligations, and next steps within 60 business days.

Do These 4 Things Now

Now that reimbursement and federal compliance may be at further loggerheads, it’s especially important to be aware of how you are contracting with payers.

Payers may take this as an opportunity to make changes to current agreements or renegotiate payment rates, Lucido says.

Evaluate carefully whether you want to be in network or out of network with individual payers.

Besides assessing your agreements and payment rates with individual payers, you should start preparing how you’re going to communicate with patients.

Providers need to make sure that their websites include surprise billing disclosures by Jan. 1, 2022. You should prepare your model notice and disclosure forms as well before you need to start deploying them, by the beginning of next year.

Keep an eye out for further regulations to be announced later this year, which may include more information on the dispute resolution process, as well as enforcement, Lucido says.

Read the final rule here