Tag: Surprise-billing

No Surprise Act:

 Author: Seymore Bones  Published Date: July 12, 2022  Leave a Comment on No Surprise Act:

Share information with your patients to help protect them from surprise billing. 

As of January 1, 2022, they have new billing protections under the “No Surprise Act” when they receive:

  • Emergency care
  • Non-emergency care from out-of-network providers at in-network facilities
  • Air ambulance services from out-of-network providers

Just click the links below for printable information.

Health Insurance Terms You Should Know
How Do I Read My Medical Bill?
What Is a Good Faith Estimate?
Health Care Notice & Consent Form - What To Know Before You Sign
In all actuality this is info we all need to know - no surprises

File a Complaint

 Author: Seymore Bones  Published Date: March 9, 2022  Leave a Comment on File a Complaint

If a provider, believes a health plan isn’t complying with the dispute resolution process, then they may contact the No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. EST, 7 days a week, to submit a question or complaint. Or, they can submit a complaint online, below. Supporting documentation may be required. We’ll send a confirmation email to the provider when we receive their complaint to notify them of next steps and let them know if we need any additional information. To check on the status of a complaint, or to see what documentation is needed, contact the No Surprises Help Desk.

Click here to review the process

US Dept. of Labor Announcement Regarding Surprise Billing Protections.

 Author: Seymore Bones  Published Date: March 8, 2022  Leave a Comment on US Dept. of Labor Announcement Regarding Surprise Billing Protections.
Link to announcement

Surprise Billing FAQs, MGMA

 Author: Seymore Bones  Published Date: February 15, 2022  Leave a Comment on Surprise Billing FAQs, MGMA

Still confused about Good Faith Estimates (GFE)?

Does Qualifying Payment Amount (QPA) sound like Greek?

Click To View the Surprise Billing FAQs from MGMA

AMA Toolkit Dissects Federal Surprise Billing Law

 Author: Seymore Bones  Published Date: January 19, 2022  Leave a Comment on AMA Toolkit Dissects Federal Surprise Billing Law

Much of the federal government’s solution to resolve certain out-of-network billing disputes without balance billing or otherwise involving patients – known as the No Surprises Act – took effect at the start of 2022.

Among other pieces physicians must familiarize themselves with, the new federal law features an independent dispute resolution (IDR) process that was intended to let physicians and insurers both make their case for fair payment. Naturally, plenty of minutiae and arcana exists within the law, and a portion of the rules for the IDR process is under a legal challenge from the Texas Medical Association and others in organized medicine.

To help physician practices understand and navigate the new law, the American Medical Association has created a toolkit, Preparing for Implementation of the No Surprises Act. The 20-page toolkit includes information on:

  • Operational challenges physicians “will need to address immediately” to be compliant with the law’s new requirements, such as when uninsured and self-pay patients must receive a good-faith estimate of charges before they receive services;
  • What services and care fall under the rules of the No Surprises Act;
  • Timetables and requirements for the IDR process; and
  • When and how facilities and physician practices can obtain a patient’s consent to balance bill for out-of-network care at an in-network facility.

AMA says it will update the toolkit “as additional guidance is available” and will develop new resources on parts of the law not already included in the toolkit.

For additional information on the No Surprises Act, you can check out TMA’s list of resources on the law, which has both similarities and differences to Texas’ IDR law governing state-regulated health plans.

Meanwhile, TMA and others are still pushing to ensure the implementation of the law is fair for physicians seeking to get paid. In late October 2021, TMA filed suit to challenge what physicians and hospitals say is an unfair piece of the IDR process outlined in federal rules. Check future editions of Texas Medicine Today for updates on that lawsuit.

AMA Toolkit

MGMA Washington Connection

 Author: Seymore Bones  Published Date: January 7, 2022  Leave a Comment on MGMA Washington Connection
  • COVID-19 PHE ends January 16, 2022 if HHS Secretary does not renew.
  • MGMA successfully advocates for sunsetting of healthcare ETS
    On Dec. 27, 2021, the Occupational Safety and Health Administration (OSHA) issued a statement on the status of its COVID-19 healthcare emergency temporary standard (ETS), confirming that it is withdrawing the ETS with the exception of the recordkeeping portions.
    Last August, MGMA urged OSHA to not make this standard permanent, due to it disrupting ongoing efforts of medical groups to balance the needs of patients against the imperative to protect employees. Although OSHA is letting this ETS sunset, it expressed its intentions to revisit the issue of protecting healthcare workers from COVID-19 in the future by issuing another standard. MGMA will urge the Agency to solicit input from stakeholders, such as medical groups, when developing such a standard.
  • Updated member resources to navigate surprise billing
    On Jan. 1, 2022, the No Surprises Act requirements prohibiting certain out-of-network balance billing and new uninsured (or self-pay) good faith estimate price transparency requirements took effect. Throughout 2021, the Biden Administration released several rules implementing these newly effective requirements. The Administration will continue to release additional rules throughout 2022 outlining the remaining patient protections that have not yet been implemented.
    The MGMA Government Affairs team has updated member-exclusive resources to help group practices better understand the requirements in place. Check out the most up-to-date resources on the MGMA Surprise Billing landing page.
  • MIPS 2021 data submission window open
    Clinicians can now submit and review data for the 2021 performance year for the Merit-based Incentive Payment System (MIPS). The data submission window closes on March 31, 2022 at 8 p.m. (ET). The Centers for Medicare and Medicaid Services provided several flexibilities for clinicians due to the COVID-19 public health emergency, including applying an automatic reweighting of performance scores for individual clinicians.
    In other MIPS updates: on Jan 1. 2022, the 2022 payment adjustment, based on clinician 2020 MIPS performance scores took effect and will be applied to Part B covered services. Additionally, looking ahead to the 2022 performance year, clinicians can now review their preliminary MIPS eligibility by signing into the Quality Payment Program website.

2nd Regulation Released Implementing No Surprises Act

 Author: Seymore Bones  Published Date: October 12, 2021  Leave a Comment on 2nd Regulation Released Implementing No Surprises Act

On Thursday, Sept. 30, the Office of Personnel Management and the Departments of Health and Human Services, Labor, and Treasury, released the second regulation implementing provisions of the No Surprises Act. On Dec. 27, 2020, the No Surprises Act was signed into law with the goal of protecting patients from receiving surprise medical bills. This rule follows prior rulemaking outlining patient protections against surprise medical bills, establishing out-of-pocket limits, and notice and consent requirements.

This rule implements dispute resolution processes for providers, patients, and health plans and takes effect Jan. 1, 2022. Consistent with the intent of the law and previous rules from the Administration, patients continue to remain harmless from outstanding surprise medical bills.

Follow these links for more information from CMS.gov.

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period
What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing (September 2021)
MGMA

News for BCBS Employer Groups

 Author: Seymore Bones  Published Date: September 28, 2021  Leave a Comment on News for BCBS Employer Groups

Sept. 24, 2021 | BCBSTX News

Update to 2022 Telehealth Services

In support of our members and employer groups, in 2022 we will continue to cover the expanded telehealth services that we’ve covered this year. This is our standard coverage.

Federal Government Releases Proposed Rule Related to Surprise Billing, Transparency

The proposed rule provides new regulations to implement sections of Consolidated Appropriations Act of 2021. Topics covered include air ambulance reporting, agent and broker compensation disclosure and reporting, and enforcement of No Surprises Act requirements

Click here to view the full article

MGMA Summary for 2020 Q4

 Author: Seymore Bones  Published Date: January 12, 2021  Leave a Comment on MGMA Summary for 2020 Q4

And What to Look for in 2021 Q1

On Dec. 21, Congress passed massive year-end legislation that includes $1.4 trillion in funding for the federal government in FY 2021, an additional $900 billion in COVID-19 stimulus funds, and various other provisions that impact medical groups. President Trump signed the bill into law on Dec. 27.

In the coming weeks, MGMA expects the Administration will issue guidance on certain provisions of the new law. This guidance is expected to provide more detail into how these provisions will be implemented and the impact on medical groups. As this information becomes available, MGMA will keep medical group practices updated and will be revising resources, such as those published in MGMA’s COVID-19 Recovery Center.


Key provisions of the law include the following:

Medicare payment

  • Increases Medicare payments across the board for CY 2021 from what was finalized in the 2021 Physician Fee Schedule (PFS) by adding $3 billion into the PFS and delaying payment of HCPCS add-on code G2211 for three years. MGMA expects that the Centers for Medicare & Medicaid Services (CMS) will release information regarding the updated payments for 2021 once it factors in the 3.75% increase to the PFS and calculates the impact of delaying G2211. We expect CMS to communicate the new conversion factor and new payment rates to local Medicare Administrative Contractors, who will update their schedules accordingly. These payment increases follow significant MGMA advocacy and will serve to offset cuts previously slated for Jan. 1, 2021. 
  • Temporarily suspends the 2% Medicare sequester from Jan. 1 through March 31, 2021. MGMA advocated for an extension of the current moratorium on Medicare sequestration authorized in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
  • Extends the work geographic index floor under the Medicare program through Dec. 31, 2023.
  • Expands access to mental health services furnished through telehealth past the expiration of the COVID-19 public health emergency. MGMA expects to see further guidance from CMS on this policy change.

Paycheck Protection Program (PPP)

  • Extends and modifies the PPP to provide further flexibilities, such as:
    • A simplified loan forgiveness application process for loans under $150,000;
    • Clarification that loan recipients may deduct forgiven PPP loans;
    • The creation of a “PPP second draw” loan for businesses that meet certain criteria;
    • The allowance of additional eligible and forgivable covered expenses;
    • The ability for certain 501(c)(6) organizations to qualify for a PPP loan; and
    • The ability to elect a covered period ending between 8 and 24 weeks after loan origination.
  • MGMA expects the U.S. Department of the Treasury to issue and update guidance to reflect the modifications made to the PPP in the coming days.

Provider Relief Fund (PRF)

  • Adds $3 billion to the $175 billion PRF and clarifies how recipients can use funds to cover “lost revenue” attributable to COVID-19. The new law allows providers to calculate lost revenues using a budgeted-to-actual revenue comparison, rather than actual year-over-year comparisons as currently required by Department of Health & Human Services (HHS) guidance.
  • This change, as well as the addition of funds, is welcome news; however, it remains to be seen how HHS will implement new clarification. Group practices should continue to monitor the PRF website for updates based on the new legislation in the coming days or weeks. 

FFCRA paid sick and family leave

  • Extends the refundable payroll tax credits for paid sick and family leave enacted in the Families First Coronavirus Reponses Act (FFCRA) through March 31, 2021, so employers may choose to continue offering paid leave to their employees. It does not, however, require employers to extend FFCRA paid sick and family leave past Dec. 31, 2020. 

Surprise billing

  • Provides patient protections from out-of-network medical bills. Nonparticipating providers at emergency facilities (or a participating provider at a nonparticipating emergency facility) will not be permitted to bill a patient beyond the allowed cost-sharing amount. Instead, the patient’s health plan will make an initial payment directly to the provider or issue a notice of denial. If the provider or plan is not satisfied with the payment, either party may initiate an Independent Dispute Resolution (IDR) process, which is overseen by a third party entity who has no affiliation with the provider or payer. Each party then submits a payment offer for consideration by the IDR entity, who selects one prevailing offer as the final payment amount.
  • This provision is set to go into effect in 2022 and will involve rulemaking from the Administration to provide certain implementation details. Following MGMA advocacy, at the last minute lawmakers included improvements to the IDR process.

Alternative Payment Models (APMs)

  • Freezes the 2020 qualifying participant thresholds required to achieve APM benefits, such as the 5% lump sum bonus. These thresholds were set to increase in 2021 to unrealistic levels, however pursuant to this legislation, will remain at the 2020 thresholds (at least 50% of Medicare Part B payments or at least 35% of Medicare patients through an advanced APM entity) through 2023. MGMA strongly supported maintaining 2020 thresholds in 2021 and beyond to allow more group practices to realize the benefits of APM participation.

The Updated Skinny on Texas’ Surprise Billing Law, MGMA

 Author: Seymore Bones  Published Date: July 22, 2020  Leave a Comment on The Updated Skinny on Texas’ Surprise Billing Law, MGMA

by Joey Berlin, July 17, 2020

The Texas Medical Association has updated its white paper on Texas’ law for settling out-of-network billing disputes involving state-regulated health plans.

The eight-page white paper, first released last December, covers the ins and outs of Senate Bill 1264, the 2019 legislation now in effect. SB 1264 took patients out of the middle of surprise-billing disputes between certain out-of-network physicians and state-regulated health plans, allowing them to settle those disputes through an arbitration process similar to the one used to settle salary disputes in Major League Baseball.

The white paper update comes after the Texas Department of Insurance  adopted a final rule touching on exceptions to SB 1264’s general ban on balance billing for out-of-network services the law covers. SB 1264 prohibits balance billing except in certain circumstances, which include required notice and disclosure.

The newly amended rules include these changes that TMA requested:

  • Legal representatives or guardians of a patient may be the people to agree to an out-of-network physician’s required notice and disclosure of a potential balance bill;
  • A physician may delegate the record-keeping of that notice and disclosure statement by allowing a practitioner’s “agent or assignee” to maintain a copy of the statement. Also, the statement only has to be maintained if the practitioner provides the medical service or supply at issue and sends a balance bill.

You can read the complete adopted rule on page 4,204 of the June 19 Texas Register.

To view the TMA updated white paper on Ink, follow this link.