Main Menu

CMS Releases Ruling Aimed at Protecting Patients from Surprise Billing – What You Need to Know

07.12.2021

New CMS guidance was recently issued that focuses on shielding patients from surprise billing.

The interim final rule was released as a method of implementing the No Surprises Act released by Congress in 2020, with most provisions taking effect Jan. 1, 2022.

Major components of the rule include:

  • A ban on surprise billing of emergency services. The rule requires that providers bill emergency services on an in-network basis without prior authorization, regardless of where the emergency services are provided. It also bans providers from issuing any other out-of-network charges to patients without notice.
  • A ban on surprise billing for ancillary services. The rule prohibits out-of-network charges for ancillary care, e.g., anesthesiology, provided at in-network facilities.
  • A ban on high out-of-network cost sharing for emergency and non-emergency services. To prevent high out-of-network cost sharing, the rule proposes that patient cost-sharing, including coinsurance and deductibles, be based on in-network provider rates. CMS defined the qualifying amount, which will be used to calculate patient cost-sharing, as the issuer’s median in-network rate for 2019 trended forward. Several factors determine how the rates are set, including the type of contract, insurance market, geographic region and rates for the same or similar services.

Though the rule’s main objective is to protect patients from surprise billing, it does allow providers to implement an opt-out process for patients willing to waive their balance-billing protections and consent to out-of-network charges. However, providers can’t implement this consent process for emergency services. Providers must publicly disclose their balance-billing process to ensure that patients are informed about their surprise-billing protections.

If you have questions or need assistance navigating the latest guidance, please feel free to reach out to Ron Present, Advisory Partner and Health Care Industry Group Leader, at 314.983.1358 (rpresent@bswllc.com) or Mark Renken, Director, Health Care Advisory Services, at 636.754.0234 (mrenken@bswllc.com).

Team

Back to Page