Friday, October 1, 2021

Feds Release Another Round of Surprise Billing Regulations

 After discussions of Surprise Billing that came and went during the Trump Administration years, in December 2020 Congress suddenly passed a major Surprise Billing law, to take effective January 1, 2022.  Accordingly, the Administration has been going through several rounds of releasing implementing regulations so the industry can get ready for changing ground-rules between providers and insurers.

An early round of regulations were released July 13 - here.   See my earlier blogs in July here, September here.

  • Now on September 30 there's a another round.  
  • Fact Sheet at CMS here.  Press release here.
  • New regulations, 520pp, here, in inspection copy.  
  • The Fed Reg typeset version will be out on October 7.

The laws put strict limits on the amount of out-of-network billing and sets both what the patient is responsible to pay and what the insurer will pay the provider as the main payment.   Some appeals and negotiations are possible.   

See also a special "No Surprises Act" webpage that's been opened up at, here.

See some early press as follows.   

  • NYT here.
  • Rev Cycle here.
  • MedCity here.
  • Stat here. *Subscription.
  • Fierce Healthcare here.  
  •     (Some further background from Sept. 8 at Fierce, here.)
  • CAP Objects to new rules here.
  • See a rapid publication (promising more) at Health Affairs, here.
  • See Healthcare Dive here ("Docs slam rule").
  • See a more general article in NEJM on "financial informed consent" - here.

As a pathologist, Table 2 caught my eye.  They assert there are 12,640 active pathologists, 44% had out-of-network claims (when serving inpatients).  Of those doctors, 44% of their claims, were out-of-network.  These numbers were net-net higher than any of the other specialties in the table (E.R. med, radiology, anesthesiology, psychiatry, cardiovascular).  Anyway, it's clear why rules and regs around surprise billing are high on the agenda of the pathology associations.
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