Surprise Billing Regulations Finalized

Surprise Billing Regulations Finalized

On August 19, the Department of Health and Human Services (HHS) released its final rules related to the Surprise Billing act. These rules clarify specific requirements under the July 2021 interim rules regarding information that group health plans and health insurance companies offering group or individual health insurance coverage must share about the qualifying payment amount (QPA).

The July 2021 interim rules prompted many legal clashes over the role that the qualifying payment amount would play in the independent dispute resolution (IDR). IDR helps healthcare providers and insurance companies resolve payment for medical services by arbitration when both parties can’t agree on an amount.

The Biden administration’s final rule has made its ruling a little more provider-friendly. The new final rule states that arbitrators “should select the offer that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.”

These final rules clarify situations where payers “downcoded” claims. A previous rule defines downcoding as claims where the payers change service codes or change, add, or remove a modifier, which can lower the QPA for the service code or modifier billed by a provider. New requirements state:

  1. Payers must notify providers when downcoding occurs, including notification that the service code or modifier was downcoded
  2. Clarification or reason of why their claim was downcoded
  3. The amount that would have been the QPA had the downcoding or modifier not been downcoded

The Biden Administration speaking through the Departments of Labor, Health and Human Services, and Treasury, said the new final rules “will help providers, facilities and air ambulance providers engage in more meaningful open negotiations with plans and issuers and will help inform the offers they submit to certified independent entities to resolve claim disputes.”

The American Hospital Association commented in a news release that they are carefully studying the final surprise bill rules to assess whether the updated rules will be sufficient to tip the balance for providers.