Providers must furnish ‘good-faith’ price estimates to self-pay patients starting next year



Regulations that would require providers to also give good-faith estimates to health plans won’t take effect in 2022 as previously scheduled.



A newly issued federal rule on surprise billing includes regulations designed to improve price transparency for self-pay patients starting in 2022.

The interim final rule with comment period (IFC) requires providers to ask about a patient’s coverage status at the time a service is scheduled. If the patient does not have insurance, “a good-faith estimate” of expected charges for items and services must be provided — generally within three business days.

The requirement also applies if the patient has insurance but does not intend to submit a claim.

The rule states that the estimate must include “any items or services that are reasonably expected to be provided in conjunction with scheduled or requested items or services and such items or services reasonably expected to be so provided by another healthcare provider or healthcare facility” along with “the expected billing and diagnostic codes for any such items or services.”

Using knee surgery as an example, the rule states that the estimate should include an itemized list of services such as professional fees, facility fees, prescription drugs and durable medical equipment. “All items or services that are reasonably expected to be provided from admission through discharge as part of that scheduled knee surgery, from all physicians, facilities or providers, [should] be included in the good-faith estimate.”

Separate estimates would be required for distinct preoperative and postoperative items and services. HHS seeks comments on the viability of expanding the requirement so that a single estimate would include related services to be furnished before and after the surgery or other primary service.

The regulations “do not require the good-faith estimate to include charges for unanticipated items or services that are not reasonably expected and that could occur due to unforeseen events.”

HHS also states that for 2022 it plans to exercise enforcement discretion in situations where the estimate leaves out charges from a co-provider. The relaxed enforcement recognizes the need for “additional implementation time to develop appropriate communication channels that may not yet exist among various co-providers or co-facilities.” 


Patient bills could be subject to arbitration


The rule establishes a dispute resolution process for situations in which the billed amount substantially exceeds the estimate. Substantially in excess is defined as more than $400 above the estimate for any provider or facility that was included.

The patient must initiate the process within 120 days of receiving the bill, file the required documentation and pay a $25 administrative fee. 


Estimates to insurers aren’t required (yet)


In the rule, HHS clarifies that the requirements don’t include submission of good-faith price estimates from providers to health plans. Although such regulations were previously issued, subsequent feedback made clear that developing the requisite infrastructure would be daunting.

In response, HHS will defer enforcement of that requirement pending further rulemaking. 


The big picture on surprise billing


The new requirements are among various billing-related regulations that take effect starting Jan. 1, 2022. A previously issued IFC established the consumer protections that will be in place, while a proposed rule set forth enforcement procedures and penalties for violations.

The requirements about good-faith estimates were included in a new rule that also established an arbitration process for settling disputes between health plans and providers over payments for out-of-network care.


Call Today: 614.706.5206

 

 

 

 

 

 

Popular posts from this blog

IMPORTANT UPDATE: Ohio Medicaid is upgrading its provider enrollment system

Effective August 1, 2022, ODM will not be accepting new provider enrollment applications or continue any in-progress enrollment applications through the MITS Provider Enrollment System. Details on the process for enrollment of new OhioRISE providers from August 1 to October 2022 will be communicated prior to August 1st. Effective October 1, 2022, all provider enrollment applications must be submitted using Ohio Medicaid’s new Provider Network Management (PNM) portal. After its implementation, the PNM portal will be the single point for providers to complete provider enrollment, centralized credentialing, and provider self-service. Provider Network Management Portal and Centralized Credentialing Beginning on October 1, 2022 the Provider Network Management (PNM) portal will accept Medicaid provider enrollments and carry out centralized credentialing functions. This transition will reduce administrative burden for providers and enable providers to focus on the more meaningful and importan...
Read more

CO Supreme Court: Hospital Cannot Enforce $229K Surprise Bill

The surprise bill stemmed from the hospital’s chargemaster rate, but the hospital did not provide this information to the patient before her surgery. The Colorado Supreme Court has ruled that a woman is not liable for her $229,000 surprise bill from a Centura Health hospital, as the hospital did not disclose the amount to her before the procedure. Lisa Melody French received spinal surgery at St. Anthony North Hospital in Westminster, Colorado, in 2014. The hospital initially estimated that the surgery would cost $57,601, with French responsible for paying $1,337 out-of-pocket. But the cost increased to $229,112 following the surgery. According to the court document, the new price tag reflected Centura’s full chargemaster rates for the surgery. Additionally, Centura determined that it had misread French’s insurance card and she was an out-of-network patient. French was left with the nearly $230,000 bill after her insurance paid $73,597 of the new charge, which was over $300,000. Fren...
Read more

Governor DeWine Announces Local Government Payments from National Opioid Settlement Begin

Image
    Ohio Governor Mike DeWine announced Friday that the first payments of funds to local governments from the OneOhio settlement with national opioid distributors have been made electronically. Local governments will determine how to use the payments, totaling more than $8.6 million, to best combat the opioid epidemic in their own communities. Following these initial payments, governments will continue receiving payments from the settlement over the next 18 years. In 2017, as Ohio Attorney General, Governor DeWine was one of the first in the nation to sue opioid makers and drug distributors for their role in flooding the market with massive amounts of highly addictive opioids. A complete list of payments made to eligible and participating political subdivisions may be found at https://nationalopioidsettlement.com/states/ohio/ . The list also indicates if the payment was made directly to the entity or, if less than $500, was redirected to the county. Questions about payments c...
Read more