September 13, 2022
The U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released final rules titled “Requirements Related to Surprise Billing: Final Rules.” These rules finalize provisions related to the No Surprises Act. The No Surprises Act officially took effect on January 1, 2022. The following are the highlights of the updated rules:
- The Agencies define the term “downcode” to mean the alteration by a plan or issuer of the service code to another service code or the alteration, addition, or removal by a plan or issuer of a modifier, if the changed code or modifier is associated with a lower qualifying payment amount (QPA) than the service code or modifier billed by the provider, facility, or provider of air ambulance services.
- If a QPA is based on a downcoded service code or modifier, the plan or issuer must provide the following with its initial payment or notice of denial of payment:
- A statement that the service code or modifier billed by the provider, facility, or provider of air ambulance services was downcoded.
- An explanation of why the claim was downcoded, including a description of which service codes or modifiers were altered, added, or removed, if any.
- The amount that would have been the QPA had the service code or modifier not been downcoded.
- Certified Independent Dispute Resolution (IDR) entities must consider the QPA and then must consider all additional permissible information submitted by each party to determine which offer best reflects the appropriate out-of-network rate.
- Certified IDR entities should evaluate whether the information relates to the payment amount offer submitted by either party and whether the additional information is credible.
- The certified IDR entity should also evaluate the information to avoid double counting information that is already accounted for by the QPA or by any of the other information submitted by the parties.
- After weighing these considerations, certified IDR entities should then select the offer that best represents the value of the item or service under dispute.
- The rules finalize provisions of the October 2021 interim final rules requiring certified IDR entities to explain their payment determinations and underlying rationale in a written decision submitted to the parties and the federal agencies.
- The final rules require that the written decision include an explanation of the information that the certified IDR entity determined demonstrated that the selected offer is the out-of-network rate that best represents the value of the item or service.
- This includes the weight given to the QPA and any additional credible information regarding the relevant factors.
- If the certified IDR entity relies on additional information or circumstances when selecting an offer, the final rules state that its written decision must include an explanation of why the certified IDR entity concluded the information was not already reflected in the QPA.
You can view the Rules Fact Sheet (Here)