The federal government recently issued final regulations revising certain aspects of the interim final regulations previously released implementing the surprise billing rules set forth under the No Surprises Act.
The rules finalize certain requirements under the July 2021 interim final rules relating to information that group health plans and health insurance issuers offering group or individual health insurance coverage must share about the qualifying payment amount (QPA).
QPA Information that Plans and Issuers Must Share
- QPA Disclosure: The July 2021 interim final rules require plans and issuers to disclose the QPA for each item or service to providers, facilities, and providers of air ambulance services with each initial payment or notice of denial of payment when the QPA serves as the amount upon which cost sharing is based.
- Downcode Defined: the Departments are finalizing a definition of the term “downcode” and requiring that plans and issuers disclose additional information if they downcode a billed claim.
- Downcode Sharing Requirements: If a QPA is based on a downcoded service code or modifier, the plan or issuer must provide the following with its initial payment or notice of denial of payment:
- a statement that the service code or modifier billed by the provider, facility, or provider of air ambulance services was downcoded;
- an explanation of why the claim was downcoded, including a description of which service codes or modifiers were altered, added, or removed, if any; and
- the amount that would have been the QPA had the service code or modifier not been downcoded.
Payment Determinations Under the Federal IDR Process
- These final rules remove the provisions that the District Court vacated in rulings in February and July 2022.
- Under these final rules, certified IDR entities must consider the QPA and then must consider all additional permissible information.
- The final rules also finalize provisions of the October 2021 interim final rules requiring certified IDR entities to explain their payment determinations and underlying rationale.
- The final rules require that the written decision include an explanation of information
- If the certified IDR entity relies on additional information, the final rules state that its written decision must include an explanation of why the certified IDR entity concluded the information was not already reflected in the QPA.
For guidance on the impact of the final rules, contact us.
Related practices: Healthcare, Managed Care, Litigation
