Latest surprise billing rule requires cost estimates, outlines arbitration process

Hospitals must provide uninsured or self-pay patients with good faith cost estimates for services, according to an interim final rule (IFR) released September 30 implementing provisions of the No Surprises Act.

The rule, Requirements Related to Surprise Billing; Part II, also details the:

• Independent dispute resolution process providers and payers can use to adjudicate reimbursement disputes
• Process to resolve cost estimate disputes between uninsured or self-pay patients and providers
• External review process for monitoring provider and payer compliance

Under the rule, a provider and a payer can enter a 30-day open negotiation period to agree on an out-of-network rate. If an agreement can’t be reached within 30 days, either the provider or the payer can begin the independent dispute resolution process. The process is arbitrated by a certified independent dispute resolution entity jointly selected by the provider and payer.

The rule describes the certification process for independent dispute resolution entities. CMS is currently seeking applications from entities that wish to become certified.

The American Hospital Association (AHA) expressed disappointment with the rule. In a statement, Stacey Hughs, AHA executive vice president, called it a “windfall for insurers.” The rule strays from the intent of the No Surprises Act and includes proposals rejected by Congress, Hughes said in the statement.

In contrast, America’s Health Insurance Plans (AHIP) praised the IFR. President and CEO of AHIP Matt Eyles said the rule conforms to the intent of the No Surprises Act. The rule’s independent dispute resolution process is the right approach and will ensure that arbitration does not lead to health insurance premium increases, Eyles said.