Skip to main content

New Year Brings Milestone Regulatory Changes To Payers, Providers, Members

Change is right around the corner for payers, providers and health plan members that affect cost-sharing and provider network directories.

One of the most contentious issues in healthcare – surprise billing – reaches a new milestone Jan. 1, 2022 as interim final rules and a clear process for many out-of-network billing goes into effect. Claims generated from out-of-network emergency services, out-of-network services at in-network facilities and air ambulance services must hold members harmless and be adjudicated at the median in-network contracted rate for a geographic area (Qualifying Payment Amount or QPA) within 30 days of receipt. QPA does not apply to those states that have the All-Payer Model or state-mandated fee schedules.  Health plans will need a grasp of various state rules to reach correct formulas for calculating payments, as self-funded plans under ERISA are no longer exempt from state rules which vary greatly. In any case, the more stringent of either state or federal rules in holding consumers harmless applies.

Ground Ambulance Charges a Notable Gap

With the QPA as a starting point, there are remedies through negotiation and independent dispute resolution that will determine what rate will ultimately be paid for a service. The stakes appear high, as that rate established in open negotiation and IDR will become the QPA for the provider and services reviewed for at least 90 days.

HealthRules Payer® may be configured to automatically promote applicable claims to in-network, and enhancements to compare QPA with Non Par and Billed amounts are in development.  Current regulations address known gaps, with an exception for ground ambulance balance billing. Slightly more than half of such rides create out-of-network bills; in some states as many as two-thirds of rides do so. The patchwork of ground ambulance service providers and local laws makes this regulation more complex. A regulatory advisory committee is studying the issue.

Provider Directories Get a Makeover

Another aspect of the No Surprises Act coming into play in 2022 is the provider directory requirement, which governs how up to date online and paper provider directories must be. As part of the “hold harmless” philosophy in which health plan members could inadvertently receive out-of-network services due to inaccurate directory listings, and building upon current provider directory initiatives, plans have new requirements to meet. Online databases must be updated at least every 90 days in a manner that can be audited for compliance and accuracy. The burden is on providers to verify their information if they want to be represented as in-network, but payers also have a responsibility to remove unverified information until certified by the provider.

Plans will have two business days to make online changes; printed directories require a date notation to indicate a publication date. Phone requests to change provider information must be handled within a business day with an auditable process to verify the work is complete. Services rendered based on incorrect information must be processed as in-network.

‘Hold Harmless’ the Watchword

The theme for both sets of regulation is to hold members harmless for costs incurred when they have no option; however, some of the nuances are still to be ironed out and there are court challenges underway as to how the regulations and rules are being interpreted.

About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.