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New Rule Initiates Health Care Surprise Billing Arbitration

New Rule Initiates Health Care Surprise Billing Arbitration

A new interim final rule issued by the federal government explains how an independent dispute resolution (IDR) process for patients and health care providers will work to resolve disputes over unscheduled “surprise” out-of-network health care charges.The rule, to be published in the Federal Register on Oct. 7, implements provisions of the No Surprises Act (NSA), signed into law at the end of last year. Issued by the U.S. Departments of Health and Human Services (HHS), Labor and the Treasury, along with the Office of Personnel Management (OPM), it is a follow-up to an initial final interim rule issued in July, which detailed a ban on high out-of-network cost-sharing for many emergency and nonemergency services when a patient has not consented to the charges beforehand.”Price transparency is a reality in almost every aspect of our lives except health care,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure. These regulations, she said, will help to ensure that health care providers and facilities “provide uninsured patients with clear, understandable estimates of the charges they can expect for their scheduled health care services.”The new rule, which requests comments, was accompanied by two fact sheets, fee guidance for 2022 and accompanying materials. The agencies also launched a new website to educate the public on surprise billing limits and to host an IDR portal for payers and providers.The Arbitration ProcessThe interim final rule applies to insurers or to self-insured employers and their third-party administrators disputing charges billed by out-of-network health care providers. These disputes typically arise after the out-of-network provider bills a patient for the difference between the charge and the amount paid by their plan, known as “balance billing.”In brief, here is how the process will work:Before initiating the federal IDR process, the disputing parties must initiate a 30-day “open negotiation” period to determine a payment rate. If negotiations fail during this period, either party may initiate the federal IDR process, and the parties may jointly select a certified IDR arbitrator to resolve the dispute. The parties will submit their offers for payment along with supporting documentation. The arbitrator will then issue a binding determination, selecting one of the parties’ offers as the out-of-network payment amount. Both parties must pay an administrative fee ($50 each for 2022), and the nonprevailing party is responsible for the arbitrator’s fee.Standard Notices”Each step in this process requires the parties to provide written notice to the other party or the federal government,” wrote Katie Keith, a former research professor at Georgetown University’s Center on Health Insurance Reforms and a contributor to the Health Affairs blog. “To aid the parties in doing so, the agencies created various standard notices,” she explained. “If a provider wants to initiate the open negotiation period, they must inform the plan or insurer and send written notice within 30 business days of an initial payment or denial of payment.”The open negotiation period then extends for 30 business days from the date of the notice, Keith explained, and “the parties must exhaust this open negotiation …

Congress Considers Commonsense Reporting Act; to Streamline ACA Filings

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Congress Considers Commonsense Reporting Act; to Streamline ACA Filings

Legislation introduced in the U.S. House of Representatives on Sept. 21, if enacted, could simplify employers’ annual Affordable Care Act (ACA) reporting of health plan information to the IRS. The bipartisan Commonsense Reporting Act of 2021 (H.R. 5318) was introduced by Reps. Mike Thompson, D-Calif., and Adrian Smith, R-Neb. A Senate version of the legislation is expected to be introduced shortly, sponsored by Sens. Mark Warner, D-Va., and Rob Portman, R-Ohio.Reducing Reporting BurdensUnder current law, employers must report annual data to the IRS under tax code Sections 6055 and 6056 during the year-end tax filing season. These provisions require HR professionals to track data each month.The Commonsense Reporting Act would allow reporting to be done prospectively before the beginning of a new coverage year, based on employee coverage during the current plan year.Research by the Society for Human Resource Management (SHRM) shows that fulfilling these requirements comes at great time and expense to employers. If an employer is unable to submit IRS forms, they may face serious financial penalties. On Sept. 9, during the SHRM Annual Conference & Expo 2021, more than 3,000 SHRM members called on Congress to act on legislation to streamline and modernize IRS reporting requirements for employers.”With 300,000-plus HR professionals and business executives as members, SHRM appreciates congressional efforts to streamline and modernize health care benefit reporting requirements,” said Emily Dickens, SHRM’s chief of staff, head of government affairs and corporate secretary. “Our membership’s expertise includes administering and reporting on health care benefits. This effort will directly impact their work.” According to a SHRM position statement:”A more streamlined, proactive reporting system would reduce burden on employers and the IRS. Additionally, such an approach would provide compliance relief by allowing employers participating in to transmit Form 1095 to employees electronically rather than requiring each form be printed and mailed.” [SHRM members-only toolkit: Complying with the Affordable Care Act]What the Bill Would DoAs summarized by the Partnership for Employer-Sponsored Coverage (P4ESC), which is made up of 16 professional associations including SHRM, the Commonsense Reporting Act would: Create a voluntary prospective reporting system. Allowing employers to voluntarily report coverage information to the IRS prospectively about their health plan, using data for the current plan year, could increase the accuracy of eligibility determinations for ACA marketplace exchange tax credits. State and federally facilitated exchanges would access information securely through a data services hub. The IRS would use the information to issue Letter 226-J tax penalty notices more accurately. Protect consumer financial security and individual privacy. ACA exchanges would have a better verification tool and real-time employer plan information for tax credit determinations, which could reduce the threat of an individual having to pay the IRS back for the value of the exchange plan. The bill also clarifies that the IRS can accept full names and dates of birth in lieu of dependents’ and spouses’ Social Security numbers and requires the Social Security Administration to assist in the data-matching process. Protects employers and streamlines compliance burdens. By enabling the employer to …

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