A few weeks ago, the Department of Health and Human Services passed an interim final rule to address the issue of surprise billing.

Here are some summary points from the order:

  • Emergency services must be billed as in-network, and prior authorization can’t be required. 
  • The patient’s copay or deductible can’t be higher than it would be if a doctor was in-network.
  • In all circumstances, ancillary care (anesthesia, surgical assistance, etc.) cannot be billed as out-of-network if the care is performed at an in-network facility.
  • All out-of-network charges must be billed with advance notice given to the patient.
  • Before a provider can bill an out-of-network rate, the provider must give the patient an easy to read and understand letter explaining that the patient must give their informed consent that they are willing to receive out-of-network care and be billed at out-of-network prices. (CMS1, Health Leaders Media2)

This rule comes under the bipartisan No Surprises Act, which was passed in 2021, and marks a huge victory for patient advocates who have been championing this legislation for years (No Surprises Campaign3). Some of the primary drivers of this legislation come from patients receiving emergent care. 

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For example, air ambulance rides can cost up to $40,000 and more often than not are billed at out-of-network rates with patients having to shoulder most if not all of that cost (No Surprises Campaign3). One aspect of this ruling that wasn’t included was ground ambulance rides, which are billed out-of-network about 51% of the time (Health Payor Intelligence4). 

The effects of this legislation will be widely felt throughout the healthcare industry, but especially for the most vital part of the healthcare landscape: the patients. Providers appear to be negatively impacted the most through this rule because they will receive lower payments for their out-of-network services. But the negative results for them become positive results for patients and payers. With not having to pay as much for out-of-network emergency care, it is expected that insurance premiums will lower, and that the percentage of bankruptcies related to healthcare (currently about two-thirds of all bankruptcies list healthcare costs as a primary reason (CNBC5)) will also diminish. 

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While this ruling doesn’t eliminate all out-of-network billing, it does address the issue of patients unnecessarily suffering from the contractual variances between different care providers and different services. Especially when it comes to emergencies. 

There remains plenty of challenges and suffering within our healthcare system, but this legislation eliminates one of the more egregious causes of that suffering. As white house official Kiran Ahuja said regarding this announcement: “Facing a difficult medical situation is challenging enough – no one should then face a surprise medical bill when they get home. This interim rule helps to protect Americans from financial ruin… by giving them new protections from unexpected medical bills.” (CMS1)

Better caring for patients is the reason we all got into healthcare, and it appears that this new ruling will stand to greatly benefit them. Championing the patient and lowering the costs of healthcare will mean that some parties will have to make less money. And while these changes may be hard for some, we feel that this legislation is a step in the right direction for the patient.

To learn more about the No Surprises Act, check out these resources below:

  1. https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills 
  2. https://www.healthleadersmedia.com/payer/hhs-unveils-interim-final-rule-surprise-billing 
  3. https://nosurprisescampaign.org/ 
  4. https://healthpayerintelligence.com/news/51-emergency-ground-ambulance-rides-result-in-surprise-billing
  5. https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html

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