Second Surprise Billing Interim Final Rule Issued

Second Surprise Billing Interim Final Rule Issued

October 15, 2021

The Second Interim Final Rule (“IFR2”) for the No Surprises Act was released on September 30, 2021, for a 60-day comment period, to become effective on December 6, 2021.IFR2 addresses the Independent Dispute Resolution ("IDR") process used to determine the out-of-network reimbursement rate when health care providers and health plans are unable to agree on a reimbursement amount. First, parties are to enter into an open negotiation period within 30 business days from the date of payment or denial by the health plan. The negotiation period must last 30 business days before parties may enter into the formal IDR process. The formal IDR process may be commenced by either party though the IDR portal following the negotiation process. Parties must select an IDR entity and pay the IDR fee in full, with the winning party to be refunded. The parties must them present their offer of settlement to the IDR entity with any information requested. The IDR entity is to presume that the Qualifying Payment Amount ("QPA"), generally the median contracted rate of a plan for a geographic region, is the correct reimbursement amount, unless a party can clearly demonstrate why this amount is incorrect. The IDR entity is to then provide a written notice of determination containing the correct reimbursement amount and the payment must be made within 30 days of the ruling.

Additionally, IFR2 contains additional protections for uninsured patients, including the requirement that a good faith estimate of anticipated charges be provided to the uninsured patient. And, IFR2 creates an IDR process for uninsured patients who receive a bill that is “substantially in excess,” defined to be $400 or more, than their good faith estimate.

The Second Interim Final Rule can be found here.

Categories: Healthcare