On August 26, 2022, the Departments of Labor, Health and Human Services, and the Treasury (together, the “Departments”) published final rules on the No Surprises Act, making changes to the administrative duties of insurance carriers, HMOs, third-party administrators, out-of-network healthcare providers, and certain other entities responsible for the Act’s implementation.
The new rules, which take effect on October 25, 2022, are narrow in scope, and include the following changes:
• During processing of claims under the No Surprises Act, if “down-coding” occurs (i.e., the group medical plan alters or replaces the medical billing codes chosen by the out-of-network healthcare provider, resulting in a lower claim payment), then the final rules impose additional disclosure requirements on the plan.
• If a group medical plan and an out-of-network healthcare provider are unable to agree on the final claim payment under the No Surprises Act, and the dispute is referred to a certified independent dispute resolution entity (“IDR entity”), the final rules require the IDR entity to consider more evidence before making its decision,
and to disregard any presumption in favor of the qualified payment amount (“QPA”) (contrary to the position previously taken by the Departments).
Click the link below to read the detailed bulletin;