CMS issues interim final rule on surprise billing. Payers, praise! Howling hospitals!


The rule sets out how payers and providers will resolve billing disputes under the No Surprises Act.

The Centers for Medicare & Medicaid Services released their interim final rule on surprise medical billing on Thursday, and payers and providers have given the long-awaited arrangements decidedly different receptions.

In short: hospitals hate it. Payers are thrilled.

The main point of contention in the final rule – which will come into force on January 1, 2022 – is the independent dispute resolution process for some off-grid billings, which assumes that the payer’s off-grid reimbursement is the starting point for negotiations.

The disputing parties will have a 30 day “open negotiation” to determine a payment. If they still disagree, they can initiate the dispute resolution process, which is conducted by a joint selection of a “certified independent dispute resolution entity” that has been authorized by CMS.

CMS says the dispute resolution process – mandated by the No Surprises Act – creates a process “that will take patients out of the midst of payment disputes, provide a transparent process for settling off-grid rates between providers and payers, and describes requirements for estimating health care costs for uninsured (or self-paid) people.

CMS Administrator Chiquita Brooks-LaSure said the final rule requires “healthcare providers and healthcare facilities to provide uninsured patients with clear and understandable estimates of the charges they can expect. for their regular health services “.

Stacey Hughes, executive vice president of the American Hospital Association, called the rule a “godsend for insurers”.

“The rule unfairly favors insurers over hospitals and doctors who actually care for patients,” Hughes said in prepared remarks. “These consumer protections need to be implemented in the right way, and that misses the mark.”

Federation of American Hospitals President and CEO Chip Kahn called the final rule a “total mistake” that flies in the face of Congress when it passed the law.

“It inserts a standard government pricing system that arbitrarily favors insurers,” Kahn said. “For two years, hospitals and other stakeholders worked with lawmakers to craft legislation that would protect patients from surprise medical bills, and last December Congress passed a bill providing for a process for settling medical bills. fair and balanced payment disputes. This regulation rejects all of that. hard work, misinterprets congressional intent and essentially puts a thumbs up on the ladder benefiting insurers over providers and will reduce patient access over time. “

Matt Eyles, President and CEO of America’s Health Insurance Plans, said the final rule “signals a strong commitment to consumer affordability and reduced health care spending through an independent resolution process. litigation which should encourage more providers to join the networks of health plans “.

“We are particularly encouraged to see the rules consistent with the intent of the No Surprises Act and to direct that arbitral awards must begin with a presumption that the appropriate off-grid reimbursement is the qualified payment amount,” Eyles said.

“This is the right approach to encourage hospitals, health care providers and health insurance providers to work together and negotiate in good faith. It will also ensure that arbitration does not result in increases in costs. unnecessary bonuses for hard-working American businesses and families. “

Thursday’s final rule is the third in a series of implementations of the Surprise Law proposed by the ministries of Health and Human Services, Labor, Treasury and the Bureau of Personnel Management.

In September, policymakers published a rule to help collect data on the air ambulance supplier industry, and in July published a rule on the protection of consumers against surprise invoicing. All rules come into effect on January 1, 2022.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


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