Final Rules Make Medical Claim Payment Process More Transparent
Final rules issued earlier this month and effective for the Jan. 1, 2022, plan year (the current year for most employer-provided welfare plans) provide details about the consumer-protection law intended to increase the transparency of certain medical claims payment processes for providers and clarify the process for providers and health insurance companies to resolve their disputes. The final rules were issued by the US Departments under the No Surprises Act (not to be confused with laws passed by some states with the same or similar names).
Under the final rules, if a plan or insurance policy issuer changes a provider or facility’s service code used for billing purposes to one that would reduce the payment to the provider or facility, the plan or issuer must now provide additional information when submitting an initial payment or a notice of denial of payment for items and services covered by the No Surprises Act.
The rules also finalize some aspects of the arbitration process. Parties or providers (including air ambulance providers), facilities, plans, and issuers may use an arbitration process known as the Independent Dispute Resolution (federal IDR) process to determine the total payment amount for out-of-network healthcare services for which the act prohibits surprise billing. The final rules include guidance for certified IDR entities on how to make payment determinations and instruct these entities that they must provide additional information and rationale in their written decisions.
The final rules also address certain provisions of the July 2021 and October 2021 interim final rules that relate to the operation of the federal IDR process and revise certain provisions considering two recent federal court decisions filed by the Texas Medical Association and LifeNet Inc. that challenged the qualifying payment amount presumption in the IDR process.
Available Resources
A DOL website contains links to rules and resources for the No Surprises Act including:
A Microsoft Word version of the Model Notice is also available on the DOL website.
