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No Surprises Act: The latest from CAQH CORE, the American College of Emergency Physicians, and consumers

Analysis  |  By Alexandra Wilson Pecci  
   November 11, 2021

Advanced EOB requirement guidance, interim final rule disappointment, and the effect of surprise bills on consumers take center stage as the No Surprises Act effective date approaches. 

With No Surprises Act requirements just around the corner and portions of the rule still in the interim stages, it makes sense that there's been a flurry of news related to surprise billing, the arbitration process, and more.

Here's a look at what some industry players have to say about surprise billing:

CAQH CORE releases advanced EOB requirements guidance: CAQH CORE released guidance for how healthcare providers and plans can meet the advanced explanation of benefits (EOB) requirement included in the No Surprises Act.

It's also hosting a webinar about those guidelines on November 17.

The guidelines include an advanced EOB workflow and implementation approaches for "good faith estimates," as well as recommendations for messaging standards, connectivity methods, uniform data content.

Among other things, the No Surprises Act requires:

  • Health plans to provide members an advanced EOB for scheduled services at least three days in advance
  • Providers and facilities to verify, three days in advance of a service and no later than one day after scheduling a service, the type of coverage the patient is enrolled in
  • Providers to give the health plan a "good faith estimate" of charges

The American College of Emergency Physicians (ACEP) speaks out: The American College of Emergency Physicians (ACEP) is calling on the Biden administration to change the interim final rule that details how to implement the No Surprises Act, which it called a "giveaway to insurance companies" that will "will undermine the entire effort to solve surprise billing."

It says that the interim final rule "would have arbiters give unequal weight to the qualified payment amount (the insurer's artificially low median in-network rate for reimbursement), rather than a balanced mix of other factors in the process."

As a result, the ACEP says this "would drive reimbursement rates lower and encouraging insurance companies to narrow their networks even further, which would make it harder for patients to get emergency care."

The ACEP also cites a November 5, letter that Reps. Tom Suozzi (D-NY), Brad Wenstrup, DPM (R-OH), Raul Ruiz, MD (D-CA), and Larry Bucshon, MD (R-IN) sent a HHS Xavier Becerra, Labor Secretary Martin Walsh, and Treasury Secretary Janet Yellen urging them to "amend the IFR in order to align the law's implementation with the legislation Congress passed."

"Unfortunately, the parameters of the [independent dispute resolution] process in the IFR released on September 30 do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes," the letter says.

The letter has an additional 125 Congressional signatories.

Surprise billing remains a problem for consumers: While stakeholders argue over and grapple with the details of how the No Surprises Act should be implemented, consumers are still feeling the pain of surprise bills.

eHealth's biannual "Health Insurance Trends" report, which included a survey of more than 6,400 consumers and 15 health insurers.

It found that 50% of the general population had a surprise medical bill in the past 12 months alone, and of these, 38% said the bill was a surprise because they didn't realize there would be an out-of-pocket cost for their care.

An additional 38% said the out-of-pocket charge was higher than they anticipated and 24% said the medical claim was incorrectly processed.

Women were more likely than men (54% vs 45%, respectively) and Hispanic people (60%) were more likely than Black (56%), Asian (52%), and white (46%) to get a surprise bill in the past year.

Only 31% of Medicare beneficiary survey said they've had a surprise bill in the past year.

Alexandra Wilson Pecci is an editor for HealthLeaders.

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