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Many challenges remain for patients, payors, and providers within the healthcare system. Major government regulations at the state and federal have tried to bring clarity to a costly system. However, these same regulations only added further challenges for everyone.

Before the No Surprises Act, many states enacted state balance billing laws, aimed at protecting patients. Due to ERISA and the Airline Deregulation Act, states lacked the authority to apply or enforce these laws regarding self-insured plans or air ambulance providers. Each state created its framework of laws some without consistency across the states. Before CMS began exploring the enforcement of these state laws, there were 18 states with comprehensive laws, 15 with partial laws, and 17 with no laws. With CMS enforcement occurring, CMS is only recognizing 4 comprehensive state laws for state enforcement and 18 states where there is a split process between the state and the federal government. The remaining 28 states plus the District of Columbia and territories all are handled through federal law.

This creates a greater challenge for the providers and payers for compliance and conformity. Insurance cards do not indicate if a patient is fully insured or self-insured. This means a provider would be unaware if state law or federal law applies. Some states allow a self-insurance company to opt into the state law but unless a provider searches the state’s website, the provider may not know the self-insured plan opted into the state law. Then some states may allow for payers and providers to utilize public payer programs or usual and customary rates to determine reimbursement, which is prohibited under federal law. Then the state laws only apply if the insurer sells insurance in that state and the insured’s policy was issued out of the state and it is for a plan type that is covered under the state law. Some states may protect HMO plans but not PPO plans or some states may only provide coverage for certain services and specialties. Some states may even define facility more loosely than federal law, thereby recognizing clinical labs as a facility. Currently, 10 states have protection for ground ambulance services that do not exist under federal law.

What about good faith estimates? While federal law indicates when notice and consent are required and by which providers, it also indicates specific timeframes and a requirement for good faith estimates. These good faith estimates must be so precise that any amount billed to a patient that is more than $400 different from the good faith estimate can be challenged by the patient through the independent dispute resolution process. This creates a significant problem for providers. Not all services are cut and dry. For example, an anesthesiologist cannot predict how long an operation will take. Those procedures can go longer if complications occur or the procedure changes during the operation. What about inpatient services based on a DRG? Hospitals do not know before the admission if the patient will be there for 1 day or 30 days. A DRG code is assigned based on the principal diagnosis and secondary diagnoses, present on admission indicator, and any principal procedure codes (ICD-10-PCS). However, the DRG does not consider the number of resources utilized or the length of stay.

Transparency in coverage is one of the biggest changes to healthcare and the most challenging. It effectively made the contracts between a payer and a provider open source. This means that neither party can hide behind a non-disclosure agreement or gag clause. Hospitals had to post their prices and contracted rates as early as 2021 but payers had to post their rates by July 1, 2022. Payers must post more information than facilities. However, some states may also require individual physicians or physician practices to post rates as well. This opens their rates to both sides and the patients. This information can be used to attempt to renegotiate contracts, but it could also be used during the federal law’s open negotiation process and independent dispute resolution process. They can also be used in the state mediation or arbitration process. The question remains will this information cause property and casualty insurers or states to explore fee schedules or changes to state reimbursement logic for workers’ compensation or auto insurance medical coverage?

Learning Objectives:

• Understand the different types of state balance billing law protections and applicability.
• Review the applicability and timeframes around notice and consent, including good faith estimates.
• Determine how facilities and payers must comply with transparency in coverage and the future of these rates.
• Learn about the potential implications between payer and provider relationships with transparency in coverage.

Areas Covered in the Session

• Applicability of state balance billing laws
• Services covered under state balance billing laws
• State payment standards
• Major differences between the state balance billing laws and the federal NSA law
• Notice and Consent Provider Applicability
• Notice and Consent Timeframes
• Good Faith Estimates
• Transparency in Pricing for Facilities
• Transparency in Coverage for Payers
• Patient Shoppable Services
• Challenges for payers and providers with shoppable services
• Challenges with good faith estimates
• Opportunities for providers and facilities to utilize data analytics
• Opportunities for payers and providers to negotiate better contractual terms or/ enter into contracts
• Possible impacts on the cost of health care
• Federal and State Balance Billing Law Process
• Federal Law Coverage
• State Protections
• The Driving Factors of the State Protections
• Payment Standards – Vary by State
• Notice and Consent
• Transparency in Coverage
• Transparency in Coverage in Negotiations and Dispute Resolution
• Dispute Resolution
• Independent Dispute Resolution
• The Explanation of Benefits (EOB)
• RARCs and CARCs
• Advanced Explanation of Benefits (AEOBs)
• Opportunities and challenges
• Future of healthcare: Trends changing the landscape

Suggested Attendees

• Professionals rendering services in a facility (e.g., hospital, ambulatory surgery center, independent clinical lab, freestanding ER)
• Revenue cycle management (RCM) companies
• Hospitals
• Ambulatory Surgery Centers
• Payers
• Practice Managers
• Collection Companies
• Air ambulance providers
• Ground ambulance providers
• Practice Management

About the Presenter