Earlier today, the Department of Labor, the Treasury, and the Department Health and Human Services Centers for Medicare and Medicaid Services (the “Departments”) issued a new directive to Certified Independent Dispute Resolution (IDR) Entities regarding issuing payment determinations for certain pending out-of-network (OON) disputes.
On February 6, 2023, the United States District Court for the Eastern District of Texas ruled in favor of the Texas Medical Association[1] and vacated portions of the final rule adopted in August 2022 (the “August 2022 Final Rule”) that applied to the Independent Dispute Resolution (“IDR”) process created by the No Surprises Act (the “Act”). [2] The August 2022 Final Rule was adopted by the Departments of Labor, Treasury and Health and Human Services (the “Departments”) and addressed, in part, the specific factors arbitrators must consider in resolving disputes between out-of-network (“OON”) health care providers/facilities and air ambulance providers (collectively, “Providers”), and health insurance plans, under the Act. This is the second time portions of final rules for the IDR decision-making methods have been vacated by this Court as a result of litigation brought by impacted Providers.
Executive Summary
The California Department of Managed Health Care (“DMHC”) issued a recent guidance interpreting the application of the No Surprises Act (“NSA”)—a new federal law prohibiting out-of-network healthcare providers from balance-billing patients for certain emergency and non-emergency services—in California. Significantly, when determining which payment and dispute resolution processes will apply in a dispute regarding the value of non-contracted emergency and non-emergency services, the NSA expressly defers to existing state law which already protects patients from receiving “surprise” medical bills, as long as such state laws conform to certain requirements set forth in the NSA. The NSA refers to such qualifying laws as “specified State law[s]”. However, the NSA does not explicitly indicate which states’ existing balance billing laws qualify as “specified State law[s]”—rather, each state must independently review the provisions of the NSA to determine if its existing balance billing laws qualify.
Continue Reading DMHC Guidance Confirms that California Law, Not the Federal No Surprises Act, Governs Payment and Dispute Resolution Processes for Certain Out-of-Network Services Provided in California
In our November 9, 2021, blog post on the No Surprises Act (“NSA”), we discussed new consumer protections against surprise out-of-network bills. In addition to protecting insured consumers from balance billing, the NSA protects uninsured (or self-pay) individuals from many unexpectedly high medical bills. Specifically, effective January 1, 2022, a provider must furnish a self-pay patient with notice and a good faith estimate (“GFE”) of the cost of care prior to all scheduled services. This includes, among other things, a GFE of the cost of office visits, therapies, diagnostic tests, infusions, surgeries and any services reasonably expected to be provided in conjunction with such scheduled services. On December 21, 2021, the Centers for Medicare & Medicaid Services (“CMS”) issued guidance on the Good Faith Estimate and the Patient-Provider Dispute Resolution (“PPDR”) process for people without insurance or who plan to pay the costs themselves.
Continue Reading Q&A: The No Surprises Act’s Protections for Uninsured (or Self-Pay) Individuals