HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.
In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in August, including payment rate updates and revised COVID-19 billing guidance.
Here are the five updates you need to know.
Prepare for your organizations' payment rates to possibly change on October 1.
In August, CMS published the fiscal year (FY) 2023 IPPS final rule. CMS projects an increase in operating payment rates by 4.3% based on a projected hospital market basket update of 4.1% reduced by a 0.3% productivity adjustment and increased by a 0.5% statutory adjustment.
This operating payment rate is significantly higher than the 3.2% rate from April's proposed rule and follows a trend with the other final payment system rules released thus far in 2022 where the payment rate in the final rule is higher than that from the proposed rule.
CMS finalized a return to using the most recent available data (including the FY 2021 MedPAR claims and the FY 2020 cost reports) for FY 2023 rate-setting with some modifications to account for any impact COVID-19 may have had. This includes calculating two sets of relative weights–one including COVID-19 claims and one excluding COVID-19 claims–and averaging those out to determine FY 2023 relative weight values. A full accounting of additional modifications CMS will make for rate-setting is discussed in the rule.
Other policies finalized in the rule include:
Approving 25 technologies for new technology add-on payments for FY 2023, but not continuing with a one-year extension for certain new technologies that are out of their newness period despite the authority to do so due to the public health emergency.
Due to certain statutory language and a recent federal court ruling (Milton S. Hershey Medical Center v. Becerra), CMS is modifying policies for teaching hospitals as well as for certain providers and cost years to address situations for applying the full-time employee (FTE) cap when a hospital's weighted FTE count is greater than its FTE cap.
As it has in other payment system rules for FY 2023, CMS is finalizing a 5% cap on any decrease to a hospital's wage index from its wage index the prior FY.
The rule also contains a variety of quality reporting program changes and several changes to policies regarding maternal health. CMS finalized a proposal to create a new "birthing-friendly" hospital designation effective fall 2023.
As mentioned previously, in April CMS proposed an IPPS increase of 3.2% for FY 2023, an additional $1.6 billion. However, that proposal drew flak from the hospital lobby. The Federation of American Hospitals (FAH) called the proposed increase "woefully inadequate."
"It does not reckon for the hyper-inflation, staffing crisis, and the continuing pandemic, which will impact resources necessary for patient care well into the future," FAH said in April.
However, the bumped reimbursement rate in this final rule "pleased" the American Hospital Association (AHA).
"This update still falls short of what hospitals and health systems need to continue to overcome the many challenges that threaten their ability to care for patients and provide essential services for their communities," AHA Executive Vice President Stacey Hughes said in a media release.
"This includes the extraordinary inflationary expenses in the cost of caring hospitals are being forced to absorb, particularly related to supporting their workforce while experiencing severe staff shortages," Hughes says. "We will continue to urge Congress to take action to support the hospital field, including by extending the low-volume adjustment and Medicare-dependent hospital programs."
The rule is effective October 1, 2022.
CMS is requesting information that may pertain to your revenue cycle.
Also this month, CMS published a request for information in the Federal Register regarding how Medicare can work to improve equity, high-quality, and person-centered care through Medicare Advantage (MA) in a way that is affordable and sustainable.
Some of the specific questions CMS asked for input on include effective approaches to handle social determinants of health, what types of supplemental benefits MA plans do or should provide, and how MA plans use prior authorization.
The use of data for MA plan and program improvement is also found throughout the request. Specific and detailed asks concern what can be done to better leverage data for better outcomes. Some examples include:
The best data to advance equity. CMS seeks better data related to race, ethnicity, and language; sexual and gender identity; people with disabilities and language/communication hurdles; cultural identity and religious preferences; socioeconomic need; and people in rural and underserved communities.
A focus on socioeconomic data. CMS adds specific questions, including MA plan challenges in "obtaining, leveraging, or sharing such data."
Supplemental benefit use and outcomes. To improve both, CMS asks what "standardized data elements" it could collect and how they would also aid DOH, equity, and cost-sharing burdens.
Applications for utilization management (UM). With a Senate bill aimed to improve PA headed to the house, CMS wants to know which of its data, if any, help with UM/PA application and how MA plan data could align for better efficiency.
Value-based contracting. Data to assess value-based contracting models within the MA program.
Competition dynamics. CMS seeks data on vertical integration and its MA market impact.
CMS released more guidance for your revenue cycle staff on COVID-19 billing.
On August 16, CMS updated its FAQsfor Medicare providers regarding COVID-19 billing. CMS published two new FAQs in the document regarding Medicare coverage and billing for COVID-19 testing done solely for travel purposes.
For example, CMS was asked if it is appropriate for a clinical laboratory to bill and accept cash payments from Medicare Part B beneficiaries for COVID-19 testing solely for the purposes of travel.
According to CMS' answer to this question, providers are required to submit claims for Medicare-covered services. However, in general, if a service is not covered by Medicare because it is not within the scope of a Medicare benefit, providers may bill and accept direct payments from beneficiaries for those services.
CMS said it strongly encourages providers to issue an advance beneficiary notice of noncoverage for care that is never covered because it does not meet the definition of a Medicare benefit, including COVID-19 testing performed solely for the purposes of travel.
Did CMS just lighten the load for your revenue cycle staff?
On August 17, CMS announced it is discontinuing the use of certificates of medical necessity and durable medical equipment information forms for claims with dates of service on or after January 1, 2023.
CMS said it reached this decision due to stakeholder feedback that these forms are duplicative and burdensome, and CMS said that submission of these forms is particularly burdensome for small or rural providers.
Another OIG audit highlights the importance of accurate coding.
On August 23, the OIG published areview of whether select diagnosis codes that Cigna HealthSpring submitted to CMS for use in the risk adjustment program complied with federal requirements.
The OIG conducted the audit by sampling 200 enrollees with at least one diagnosis code that mapped to a hierarchal condition category (HCC) for 2015. This resulted in 1,470 HCCs associated with these enrollees. The OIG found that 69 of the 1,470 HCCs were not supported in the medical record, a far lower error rate than the OIG typically finds in these audits.
The OIG also found that there were an additional 18 HCCs for which the medical records supported diagnosis codes that Cigna HealthSpring should have submitted to CMS but did not.
Therefore, the risk scores for these sampled enrollees should have been based on 1,426 HCCs instead of 1,470, and Cigna HealthSpring received $39,612 in net overpayments for these sampled enrollees.
The OIG recommended that Cigna HealthSpring refund the federal government for the $39,612 in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes used in risk-adjusted payment calculations.
Cigna HealthSpring disagreed with the OIG's findings and recommendations from the draft report and questioned the OIG’s audit and statistical sampling methodologies. The OIG revised some of its original findings and recommendations but maintained that its methodologies were reasonable and properly executed.
The number of non-physician providers (NPP) submitting radiology service claims saw an increase from 2017 to 2019.
According to a study by the Harvey L. Neiman Health Policy Institute, the number of radiology practice employed NPPs submitting Medicare claims increased from 523 in 2017 to 608 in 2019, a 16.3% relative increase. NPP total work relative value units increased to a slightly greater extent (17.3%) and varied significantly across categories of services, the study said.
When the researchers assessed claims submitted by NPPs by clinical category, 98.7% of NPP services were involved clinical evaluation and management, invasive image-guided procedures, and imaging interpretation, the study said. Among these, invasive procedures accounted for the highest proportion of total NPP work relative value units.
Evaluation and management services accounted for the second highest number of NPP work relative value units and exhibited a 40% increase from 2017 to 2019: from 80 to 111 thousand, respectively. This made up a growing proportion of NPP work effort.
Regarding the potential impact of the observed growth in NPPs billing for radiology services, senior study author Richard Duszak Jr, MD, said, "Our aggregate claims-based analysis does not allow us to study comparative outcomes of services rendered by NPPs nor opine on whether the observed trends are either good or bad for the specialty or its patients. Such questions will require further study and analysis."
The study, published in the Journal of the American College of Radiology, was based on CMS' databases of doctors and clinicians who participated in Medicare.
As more claims roll in and staffing needs deepen, revenue cycle leaders should work on solutions to make up for potential lost revenue.
Patient volumes and subsequent claims will only continue to increase. In fact, medical claims are now on the rise after being suppressed during the early stages of the COVID-19 pandemic.
On top of this, there is mounting pressure on hospital margins. Between June and July of this year, hospitals' financial performance plunged, according to the latest National Hospital Flash Report from Kaufman Hall.
As healthcare organizations look to strengthen the bottom line coming out of the pandemic, it will be increasingly important for leaders to address revenue cycle management gaps—and do so while balancing the lack of staffing.
Belinda Cridge, revenue cycle management expert at HGS Healthcare, spoke with Healthleaders to discuss what revenue cycle leaders can do to alleviate these issues as pressure intensifies.
Increasing revenue and closing gaps
"With inflation at a 40-year high everyone has less buying power, which will likely result in a larger volume of self-pay, accounts-receivable balances." Cridge says.
This is why it's important for revenue cycle leaders to develop processes to collect payments pre-service and provide patients with better good-faith estimates.
"Another area of revenue loss is typically retro-eligibility and coordination of benefits. Developing exception reports, retro-eligibility reports, and paid-claim databases are some of the best ways to avoid black holes as it relates to this area of loss," Cridge said.
Pinpointing the area within your revenue cycle with the most gaps is also very important.
Within revenue cycle management, clinical denials for medical necessity and level of care downgrades are costly. Post-pay audits were temporarily put on hold during COVID-19, and now organizations are seeing a huge rise in these audits, Cridge says.
"Data science and analytics can help providers track root causes of unpaid claims and avoid these going forward," Cridge says. "Payer rules are cumbersome and some providers, by matter of routine process, provide certain levels of service irrespective of the payer."
While creating a plan of action for revenue cycle leaders is a great start, it can seem like an uphill battle as revenue cycle staffing shortages take hold.
According to a recent survey, more than 57% of health systems have more than 100 open roles to fill, with one in four finance leaders needing to hire more than 20-plus employees to fully staff their revenue cycle departments.
Since staffing and revenue cycle talent shortages will continue in the near-term and exacerbate the pressure on cost reduction, Cridge says she recommends three steps to immediately enhance the revenue cycle to help increase the bottom line and ease staffing deficiencies.
One: Invest in a consultative review of accounts receivable to identify the top three to five areas causing the most revenue bleed and develop plans and timelines to fix them.
For example, billing processes—from bill creation through payer acceptance—can greatly benefit from being fully automated, Cridge says.
"Automating these processes are typically inexpensive and can have an immediate impact on revenue," she said.
Two: Review your small balance write-off policies.
"It's easier to get small balance claims paid if there's a vendor partner who has robust services and the depth of experience to monitor and work through these efficiently," Cridge said.
Three: Develop post-pay audit processes by payer.
Significant dollars are lost due to upfront tasks not being done to avoid recoupments, Cridge said.
Cridge has put her own tips to work as she recently helped to leverage data analytics to identify trends in denials/underpayments for an organization.
The initial findings showed that, over a period of two years, one payer underpaid $120K in oncology payments, while another payer did not pay a single appeal, she said. Cridge also found that there were 14,000 unnecessary follow-up attempts on claims that were being processed to pay.
"Revenue cycle leaders should invest in a data center, a data scientist, and revenue cycle subject matter expert to help make up lost revenue. The initial set-up may be overwhelming, but the ongoing control will reduce the need for manual trending, alleviate staffing issues, and avoid revenue loss," she says.
Leaders have started turning to technology to alleviate staffing shortages, but what can they do when implementing new technology isn't an immediate option?
Revenue cycle leaders have started turning to technology to fill gaps as staffing shortages seem to have hit a high. In fact, one in four finance leaders need to hire more than 20-plus employees to fully staff their revenue cycle departments.
But what can revenue cycle leaders do when implementing new technology isn't an immediate option?
For a short-staffed department, filling positions is a priority. But that's easier said than done in the current labor market. Attracting job candidates and selecting the right person for the job have always been challenges, but revenue cycle leaders are discovering that the pandemic has fundamentally changed what job seekers are looking for and what they're willing to compromise on.
Specifically, employees are looking for remote work, according to Stacey McCreery, MBA, and Julie Teixeira of ROI Search Group. On an episode of The Revenue Integrity Show: A NAHRI Podcast, McCreery and Teixeira discussed how the expansion of remote work has affected hiring and staff retention.
Although the initial transition to remote work challenged some, most employees quickly found the benefits outweighed the drawbacks, according to McCreery and Teixeira. In addition, some organizations discovered moving nonclinical departments off-site freed up valuable real estate on campus and reduced overhead costs.
Organizations that still expect to bring all staff back on-site on a full-time basis could find themselves at a disadvantage in the job market, McCreery and Teixeira said.
Organizations need to keep remote and flexible work options on the table to remain competitive. However, this can be a tough sell for senior leadership accustomed to traditional work arrangements and reluctant to commit to long-term changes.
"They want to see people in their seats, and they want to be able to walk around and see what they're doing," Geneva Schlabach, co-founder and CEO of VISPA, recently told the National Association of Healthcare Revenue Integrity (NAHRI). "I think it's going to have to be a progressive shift to allowing more of a hybrid workforce. "
A VISPA client initially resisted extending remote and hybrid work options, Schlabach says. However, as open positions went unfilled, they eventually settled on a hybrid work model that allowed them to remain competitive in the job market.
It's not an all-or-nothing scenario. If leaders remain flexible with work-from-home options, it reverberates through the culture and staff become more flexible in return, she says.
Leaders should lean into change when staffers depart, Schlabach says. Take a careful look at everything, from job duties to job titles, and consider what should stay as-is and what needs a refresh.
Perhaps a revenue cycle department had multiple levels of managers and directors and a complex hierarchy of staff involving tiers of team leads. Reevaluate the structure to determine whether this still make sense. If new workflows and priorities are developed, should old titles and job descriptions be grafted onto them without change?
"I believe that we are at a time within healthcare that we do have to relook at those titles," she says. "We may have had this corporate structure that was a lot more stringent at one time that we can maybe ease up on some of that and do things differently."
CMS recently announced the suspension of prior authorization requirements for specified orthoses prescribed and furnished urgently or under special circumstances.
Prior authorization requirements for specific durable medical equipment, prosthetics/orthotics, and supply codes will be suspended under certain circumstances, CMS announced.
CMS explains that due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization (such as when the two-day expedited review would delay care and risk the health or life of the beneficiary), it is suspending prior authorization requirements indefinitely for these services.
The recently published FAQ addresses questions related to the implementation of the No Surprises Act.
The Departments of Health and Human Services, Labor, and Treasury recently released a series of frequently asked questions (FAQ) related to the No Surprises Act.
The FAQs cover common questions including balance billing prohibitions, the application to plans without a network or with a closed network, and emergency services provided in a behavioral health crisis facility.
For example, one question asks if the surprise billing provisions of the No Surprises Act apply in the case of a group health plan or group or individual health insurance coverage that generally does not provide out-of-network coverage.
In this instance, the answer is yes. According to the FAQ, the No Surprises Act’s protections regarding emergency services, non-emergency services furnished by a nonparticipating provider with respect to a visit to a participating facility, and air ambulance services apply if those services are otherwise covered under the plan or coverage, even if the plan or coverage otherwise does not provide coverage for out-of-network items or services.
This FAQ comes on the heels of a new final rule and additional guidanceto further implement the independent dispute resolution process and require payers to provide additional information to providers about the qualifying payment amount.
Insurers may be calculating median in-network rates for specialty services using contracted rates for services that were never negotiated, study says.
In possible violation of the No Surprises Act, health insurance company calculations of qualified payment amounts (QPA) for anesthesiology, emergency medicine, and radiology services likely include rates from primary care provider (PCP) contracts,a new study says.
The study conducted by Avalere Health and commissioned by three national physician organizations examined a subpopulation of PCPs and determined that contracting practices may directly impact the QPA.
"Despite the law's directive that QPA calculation be based on payment data from the 'same or similar specialty' in the same geographic region, insurers may be calculating median in-network rates for specialty services using PCP contracted rates for services that were never negotiated, may never be provided by those physicians, and may never be paid," the study said.
This method may violate the No Surprises Act law and produce insurer-calculated QPAs that do not represent typical payments for these services, the study said.
In the study, 75 primary care practice employees who have a role in contracting with insurers were surveyed regarding whether they contract with insurers for services they rarely or never provide, as well as negotiation practices related to these services.
68% of respondents had services that they rarely provide (fewer than twice a year) included in their contracts, and 57% of respondents had services that they never provide included in their contract, the survey found.
"This new research raises significant questions about the accuracy of insurer calculated QPAs," said American Society of Anesthesiologists President Randall M. Clark, MD, FASA. "We have received reports of extremely low QPAs that bear absolutely no resemblance to actual in-network rates in the geographic area; yet these same rates are being used by insurers as their initial payment."
The American Society of Anesthesiologists, the American College of Emergency Physicians, and the American College of Radiology are calling on policymakers to eliminate the QPA as the main factor in arbitration and ensure the integrity of the QPA by insisting they be calculated based on "same or similar specialty" in-network rates.
This would mitigate "the unintended consequences of relying on health insurers' median in-network rates based partially on data from providers who don’t actively negotiate those rates," said Gillian Schmitz, MD, FACEP, president of the American College of Emergency Physicians. "Physicians rely on fair reimbursement to keep their doors open and continue providing lifesaving medical care to their patients."
Ongoing hurdles in scheduling, reimbursement, and collections compound difficulties for a healthcare industry already under stress a recent study says.
Medical Group Management Association (MGMA) recently released a report detailing new benchmarks related to the adoption rate of value-based reimbursement and other hurdles revenue cycles frequently face.
The report found that the average rate of value-based care only accounts for approximately 5.5% to 14.74% of revenue, with primary care and surgical specialties reporting lower revenue shares from value-based contracts in 2021 and nonsurgical specialties attributing 14.74% of total medical revenue to value-based contracts, the report said.
Other aspects of the revenue cycle were also studied in the report.
According to the MGMA, the return of patient volume in 2021 led to shifts in appointment scheduling benchmarks, as higher demand for care saw no-show rates hold steady and an uptick in cancellation rates which has put a large burden on revenue cycle staff.
Overall patient portal usage improved from 2020 to 2021, with a significant increase in patient logins, the MGMA found.
The study also found that increased care volumes, claim denials, and staffing shortages combined to spur concerning shifts in billing and collections benchmarks, as copay collections at time of service declined and charge-posting lag times increased for specialist practices.
Also, the percentage of claims denied on the first submission doubled across primary care, nonsurgical, and surgical specialties, the study noted.
“The medical workforce is grappling with burnout, staffing declines, decades-high inflation, operational challenges and a dynamic reimbursement environment that affects providers across the board,” said Dr. Halee Fischer-Wright, MD, MMM, FAAP, FACMPE, president and chief executive officer of MGMA.
“This report reveals how addressing scheduling errors and billing denials could help relieve the financial burden on health groups, moving them toward value-based care that promotes the welfare of physicians, staff, and patients.”
The report includes data from more than 2,300 organizations across multiple specialties and practice types.
While some organizations already have systems in place to adhere to price transparency requirements, opportunities still exist to adjust outdated revenue cycle processes.
The No Surprises Act, which became effective January 1, requires hospitals to post the prices for their most common procedures as well as offer a patient-friendly tool to help shop for 300 common services.
Unfortunately, most organizations are behind in adhering to this requirement—still.
Earlier this year,JAMA published a study that concluded that out of the 5,239 hospital websites evaluated, roughly 51% of hospitals did not adhere to either price transparency requirement.
Almost 14% of hospitals studied had a machine-readable file but no shoppable display, while 30% of hospitals had a shoppable display but not a machine-readable file, according to the study. It also found less than 6% of hospitals were compliant with both components of the mandate.
Of the hospitals studied, 5.1% were in total noncompliance as they did not post any standard charges file, and 51.3% failed compliance because the majority of their pricing data was missing or incomplete.
While some organizations now have systems in place to help them adhere to the new rules, opportunities still exist to revisit outdated revenue cycle processes to better comply with these regulations.
Connie Lockhart, director of strategy and operations at Impact Advisors, discussed with Healthleaders six key strategies that revenue cycle leaders can use to increase price transparency, mitigate the risk of surprise billing, and support efforts to improve the patient experience through enhanced revenue cycle processes.
Before diving into the six key strategies, when first shoring up price transparency processes (and as mentioned in the studies above), there are two main requirements that organizations need to adhere to immediately.
"Revenue cycle leaders need to first make sure they are following CMS' guidelines to complete a comprehensive, machine-readable file of all services and items," she says. "Ensure all requirements are met—like how a separate file must be posted for each hospital. And be cognizant of multiple hospitals operating under a single hospital license with different sets of standard charges."
Also, ensure that list is posted on a publicly available website.
Once completed, make sure to post a display in a publicly available website of 300 shoppable services in a consumer-friendly format. This should include the 70 CMS-specified, shoppable services, Lockhart says. Revenue cycle leaders should also establish a cadence to ensure both displays are updated annually, Lockhart says.
Once the basics of price transparency are in place, revenue cycle leaders can then move to streamlining other areas of the requirement. Here are six key strategies Lockhart suggests.
Shore up your scheduling
Improve the patient experience with better access to scheduling appointments and verifying patient eligibility, Lockhart says.
For eligible self-pay patients, revenue cycle leaders should ensure timelines are in place for governance of the No Surprises Act. It is the provider’s responsibility to verify if the patient is self-pay, so looping in front-end revenue cycle staff to address this task is a must.
For example, if a patient schedules more than ten business days in advance of a service, an organization has three days to issue a good faith estimate. If a patient schedules three days out, staff only has one day to issue the estimate.
Refine those good faith estimates
Patients are consumers, Lockhart says, so it’s important to establish expectations regarding the process for collecting out of pocket expenses. A lot goes into good faith estimate requirements, so it's essential for revenue cycle leaders to stay up to date on those intricacies.
For example, for services provided in 2022, patients can dispute medical bills that are $400 or higher than the good faith estimate that was provided.
For self-pay patients who do not have health insurance or choose not to use it, the good faith estimate is applicable, Lockhart says.
Work on collection communication
Convert the good faith estimate into cash collections to make it a smoother process for both the patient and the organization, Lockhart says.
Implementing scripting, automation of a patient estimator tool, and training for all pre-service/registration staff is key to ensuring timely and consistent communication and collections.
Leverage price transparency to build patient trust
One positive aspect of price transparency for organizations is that it can help build trust by providing patients the cost of service prior to receiving services, Lockhart says.
In order to build this trust with patients, revenue cycle leaders must make sure processes are streamlines and compliant.
"Ensure compliance with pricing transparency and good faith estimates by utilizing the CMS requirements as a baseline to assist in your hospital's review of the hospital price transparency final rule and complete a gap analysis to identify processes/elements that are not aligned with the requirements," Lockhart says.
It's also essential that your chargemaster is easily accessible, and that revenue cycle leaders perform quality checks to include bill audits. Lockhart says this strategy will ensure there is timely, consistent, and accurate communication with the patient regarding the cost of care before both the service and the bill.
Being timely, consistent, and accurate in your price transparency and estimates will build that trust and ensure a positive patient financial experience.
Train staff on point of service collections
Educate and train revenue cycle staff to be able to clearly communicate and explain the good faith estimate to patients, Lockhart advises.
Including scripting and frequently-asked-question handouts will help front end staff better communicate with patients about these prices and bills.
Resolve patient cost share
Revenue cycle leaders can reduce denials and self-pay vendor costs by resolving patient cost share on the front end, Lockhart suggests.
To do so, it's important to implement governance and reporting for point of service collections, and to track and monitor point of service collections (e.g., expected vs. actual payments) on a monthly basis, Lockhart says.
CMS regulations and accompanying surprise billing updates are changing faster than revenue cycle leaders can keep up.
The surprise billing ban was put in place by CMS to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment. While beneficial for patients, organizations have long shared their distain of the burden this causes for revenue cycle staff.
Revenue cycle leaders need to stay informed of this requirement in order to be compliant and ensure a positive patient financial experience. Review the most recent surprise billing stories from HealthLeaders.
A federal judge denied a New York doctor's lawsuit against the No Surprises Act, dismissing the request for a preliminary injunction and ruling that the law is constitutional.
U.S. District Judge Ann Donnelly rejected surgeon Daniel Haller's injunction to blow the law, which was filed on December 31, 2021, the day before the No Surprises Act took effect.
Haller and his private practice, which performs procedures on patients who are admitted after an emergency department visit, alleged in the complaint that the law is unconstitutional and deprives providers the right to be paid a reasonable payment for their services due to the independent dispute resolution process.
Several aspects of the surprise billing mandate went into effect on January 1 of this year, including federal protections against balance billing, uninsured and self-pay good faith estimate requirements (GFE), continuity of care protections, and provider directory requirements.
While the policies have been beneficial for patients, MGMA says the requirements have created administrative burden for providers as the interim final rules were published with minimal time before implementation.
The workgroup takes aim at the GFE convening provider/facility provision saying it has significant concerns with how this part of the act can be successfully adopted by two providers.
In the letter, WEDI recommends HHS consider an initial phase of the GFE requirement initiated by a patient request, extend the enforcement discretion period, identify standards-based solutions, and phase in the one- and three-day time requirement.
WEDI says these issues should be expeditiously addressed by HHS to ensure successful implementation of the legislative provisions of the act.
"While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement," stated Charles Stellar, WEDI president and CEO.
Yet 20% of respondents in the Morning Consult survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.
Unexpected charges haven't just been an issue after the fact. The survey found about one in four adults delayed or skipped medical care because they were concerned with receiving a surprise bill. Emergency room care suffered the most in this facet, with 14% of respondents saying they did not seek care, while another 14% say they hesitated but ended up receiving care.
