No Surprises Act Final Rule

New rules have been issued to address public feedback on the No Surprises Act. They include efforts to increase transparency and provide guidance for resolving billing disputes. Find out more about these important changes.

A medical bill and a stethoscope.

On August 22, 2022, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury issued a final rule that makes changes to the No Surprises Act. The changes were based on feedback received from the public after the interim rules were published in July and October of 2021. Here is a summary of the finalized rule:

  • Increased disclosures: Healthcare payers are now required to provide more information to healthcare providers about the qualifying payment amount (QPA).
  • Guidance for independent dispute resolution (IDR) entities: The rule provides guidance to certified IDR entities on how to consider the QPA and other factors when selecting an offer in the IDR process.
  • Additional requirements for IDR explanations: Certified IDR entities must now include additional details in their written explanations, stating the rationale for their determinations.

Let’s discuss each of these changes in more detail:

Additional Qualifying Payment Amount Disclosures

Based on feedback, the Departments recognized the need for more transparency in calculating the QPA. Payers must now disclose if services have been “downcoded” (changed to a lower payment code). They must explain why the claim was downcoded and provide details about the altered service codes and the payment amount that would have been applied if no downcoding occurred.

Independent Dispute Resolution Guidance 

Recent court rulings challenged the methodology for selecting offers in the IDR process as outlined in the interim rules. The final rule clarifies that certified IDR entities should consider the QPA first, but also weigh other credible information provided by the parties. The Departments encourage IDR entities to evaluate the credibility of the information and give weight only to credible sources. However, another lawsuit has been filed challenging this methodology.

Written Explanation Requirements for Certified IDR Entities

Certified IDR entities already had explanation requirements, but the final rule adds further clarity and consistency. Explanations must now include information on why the offer selected as the out-of-network rate best represents the value of the qualified IDR item or service, the weight given to the QPA, and any additional credible information considered. If the certified IDR entity relied on additional information, they must explain why it wasn’t already reflected in the QPA.

These requirements aim to promote transparency and fairness in the Federal IDR process and provide valuable information for future policymaking.

Overall, the final rule addresses important aspects of the No Surprises Act, enhancing disclosures, providing guidance for IDR entities, and requiring more detailed explanations.

Get Legal Support

Are you a healthcare professional affected by the recent changes to the No Surprises Act? Our healthcare lawyers are here to help you navigate the complexities of the new rule. If you operate in any state where we have licensed attorneys, schedule a consultation today to discuss how we can support your practice and ensure compliance with the updated requirements. 

 This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.

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