Feds Release New Surprise Billing Rules
By Sean Price

Although federal lawmakers passed consumer protections against surprise and balance billing, the new law punted a lot of important details about enforcement to the federal rulemaking process. 

Some of those details are demystified now that the Department of Health and Human Services, Department of Labor, Department of the Treasury, and Office of Personnel Management have published an interim final rule spelling out how key aspects of the law will be implemented. An interim final rule may be changed later if “warranted by public comments,” according to the federal rulemaking process. 

The Texas Medical Association played a role in keeping the federal process fair for physicians. TMA is studying the regulations and will weigh in before the public comment deadline on Sept. 7. 

Among other things, the rule: 

  • Bans surprise billing for emergency services regardless of where they are provided. All emergency services must be treated as in-network without requirements for prior authorization.
  • Bans high out-of-network cost-sharing for emergency and nonemergency services. Patient cost-sharing, such as coinsurance or a deductible, must be based on in-network rates and cannot be higher than if the services were provided by an in-network physician.
  • Bans out-of-network charges for “ancillary care,” such as care from an anesthesiologist or assistant surgeon. These services must be charged at in-network rates in all circumstances.
  • Bans other out-of-network charges without advance notice. Physicians, other health care professionals, and facilities must give patients a plainly written consumer notice explaining that patient consent is required to receive care on an out-of-network basis at higher out-of-network rates.
  • Creates a complaint system for consumers to address bills they consider illegal. 

The rule will apply to health plans and health insurance issuers for plan and policy years beginning on or after Jan. 1, 2022, according to the Centers for Medicare & Medicaid Services. Other regulations stemming from the law are scheduled to be released later this year.

Last Updated On

July 16, 2021

Originally Published On

July 15, 2021

Sean Price

Reporter

(512) 370-1392

Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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