The Biden administration moved one step closer to banning surprise medical bills from radiologists and other providers, unveiling an interim final rule on Thursday.
HHS’ action begins the process of officially implementing the No Surprises Act approved by Congress last December. The rule would prohibit unexpected bills for emergency services, stipulating that all EM care must be treated on an in-network basis without requirements for prior authorization.
It would additionally outlaw out-of-network charges for ancillary care—from radiologists, anesthesiologists or other providers—at an in-network facility “in all circumstances.”
“No patient should forgo care for fear of surprise billing,” HHS Secretary Xavier Becerra said July 1. “Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs.”
In addition, the final rule would ban forcing patients to share out-of-network costs for both emergency and nonurgent services. Any co-insurance, deductible or other cost-sharing cannot be higher than if such services were provided by an in-network physician. Those charges must be based on in-network provider rates, the announcement noted. Providers and facilities must additionally provide patients with plain-language, advanced notice explaining that their consent is required to receive care on an out-of-network basis before sending a bill at the higher rate.
Out-of-network rates will be based on several considerations, including an All-Payer Model Agreement under the Social Security Act. If no such applicable amount exists it would defer to the state law and, absent that, an amount agreed upon by the health plan and provider or facility. In cases where none of the three apply, the an independent arbitrator would settle the dispute.
The American College of Radiology has advocated for a baseball-style arbitrator to resolve doc-insurer disputes around out-of-network rates. The interim rule does not yet spell out this process, with plans to do so in future rulemaking. ACR said late Thursday that it will to conduct a “thorough review” of the rule and issue a detailed summary in the coming days.
Both bipartisan House lawmakers and the college recently urged the administration to ensure the arbitration process is fair and balanced. They’re concerned about the possibility of using artificially low payment rates that might incentivize insurers to keep providers out of network.
HHS is now accepting comments on the rule and will implement it on or after Jan. 1, 2022. You can read the agency’s two facts sheets and the 411-page rule itself for additional information.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.