US Departments of Labor, Health and Human Services and Treasury Release Final Rules to Clarify Federal Process for Surprise Medical Billing Protection | Clark Hill PLC

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Final rules make medical claims payment process more transparent

Final rules released earlier this month and effective for plan year January 1, 2022 (the current year for most employer-provided social assistance plans) provide details on the law. on consumer protection intended to increase the transparency of certain medical claim payment processes for providers and to clarify the process for providers and health insurance companies to resolve their disputes. The final rules were issued by 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 an insurance plan or policy issuer changes a provider’s or facility’s service code used for billing purposes to one that would reduce payment to the provider or facility , the scheme or issuer must now provide additional information when submitting an initial payment. or a notice of refusal of payment for the articles and services covered by the law without surprises.

The rules also finalize certain aspects of the arbitration process. Parties or vendors (including air ambulance providers), facilities, plans, and issuers may use an arbitration process known as the Independent Dispute Resolution Process (Federal IDR) to determine the amount total payment for out-of-network health services for which the act prohibits surprise billing. The final rules include guidance for certified IDR entities on how to determine payments and direct those entities to provide additional information and justification in their written decisions.

The Final Rules also address certain provisions of the July 2021 and October 2021 Interim Final Rules relating to the operation of the federal IDR process and revise certain provisions in light of two recent Federal Court decisions filed by the Texas Medical Association and LifeNet Inc. challenging the presumption of eligible payment amount in the IDR process.

Resources available

A DOL website contains links to rules and resources for the law without surprise, including:

A Microsoft Word version of the notice template is also available on the DOL website.

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