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Federal changes providers should know about in the new year

Posted by Alyssa Malmquist on December 21, 2021
Alyssa Malmquist
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There are two federal changes that impact the health care industry, effective January 1, 2022: the No Surprises Act (as part of the Consolidated Appropriations Act of 2021) and the Transparency in Coverage rule. Both directly apply to commercial and self-insured coverage. Continue reading to learn more about how these federal changes impact you as a provider.

The No Surprises Act has many touchpoints on the provider community, including no surprise billing, updated member ID cards, and provider directory changes. See below for sections of the No Surprises Act that have the most direct impact on you and your operations.

  • Balance Billing Members: The No Surprises Act protects members from ‘balance billing’ for three scenarios:
    • Emergency Room Care
    • Professional services rendered by a Non-Participating provider during admission at a Participating Facility; and
    • Air Ambulance transportation

These services should be covered as in-network and include a requirement that health plans make a payment directly to the out-of-network provider.

  • QPA and IDR requirements: To prevent members from receiving unexpected bills for certain services, QPA and IDR requirements have been updated. Out of Network Providers rendering specified (ER, air ambulance, or care by a non-participating provider at an in-network facility without informed consent) services may be reimbursed via a Qualified Payment Amount (QPA) methodology and may exercise an external rate negotiation through a new federally operated Independent Dispute Resolution (IDR) entity.
  • Member ID cards: To help members better understand their cost-sharing responsibilities, plans will update their ID cards in the new year to reflect their in-network and out-of-network deductible—and their maximum out-of-pocket requirements.
  • Provider Directory: Beginning January 1, 2022, new federal requirements in the No Surprises Act have placed greater importance on provider directory accuracy. Health plans will be required to verify provider directory information every 90 days and remove providers from directories if unable to validate a provider’s information.
  • Cost-share estimator: Both the Transparency in Coverage final rule and the No Surprise Act include similar requirements for a price comparison tool for real-time estimates of cost-share for covered items and services—with different effective dates (the No Surprises Act was January 1, 2022). In recognition of the duplication, the federal government will defer enforcement of the No Surprises Act to plan year January 1, 2023, to align with the Transparency in Coverage requirements. Massachusetts has required a cost-share estimate since 2012, and we plan to leverage our existing cost estimator tool for this new federal requirement.
  • Advance Explanation of Benefits (AEOB): To keep patients informed prior to certain services, a member will be able to request a pre-service cost estimate after scheduling a service with their provider. AllWays Health Partners will offer an interim process for 1/1/22 as the final federal rules have not been published.
  • Prescription Costs & Impact on Premium: This new reporting requirement, among other things, identifies high-cost drugs and their impact on commercial premiums; it will be submitted to the federal government. This report will be due 12/27/2022 based on pending guidance.
  • Provider gag clauses: This requirement ensures that provider contracts do not include ‘gag clauses’ that would interfere with certain requirements within the No Surprises Act and Transparency in Coverage.
    The Transparency in Coverage rule has two main requirements on health plans:
  • Cost Calculators: These are personalized, real-time estimates of OOP costs for covered items and services via an internet-based tool and paper (upon request) before enrollees seek care.
  • Public Display: Machine-readable files with all in-network rates, historical allowed amounts, and billed charges for out-of-network providers, as well as negotiated rates and historic net prices for prescription drugs. These files will be published before the deferred effective date, 07/01/2022. The prescription drug files are deferred pending future federal rulemaking.

For more information, visit cms.gov




Topics: Providers

Disclaimer: The content in this blog post represents the clinical opinions of the providers at AllWays Health Partners and is based on the most currently available clinical and governmental guidance.

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