Becker's Hospital Review

8 CFO / FINANCE CMS unveils surprise billing rule: 9 things to know By Alia Paavola C MS unveiled July 2 the first in a series of rules aimed at shielding patients from surprise billing. e interim rule addresses several provisions in the No Surprises Act passed by Congress last year. e provisions outlined in the proposed rule will not take effect until Jan. 1, 2022. Nine things to know about the rule: 1. Ban on surprise billing for emergency services. e rule bans surprise billing for emergency services, regardless of where they are provided. Providers are required to bill emergency services on an in-network basis without prior authorization. 2. Ban on high out-of-network cost-shar- ing for emergency and nonemergency ser- vices. CMS proposed that patient cost-shar- ing, including coinsurance and deductibles, be based on in-network provider rates. is means that cost-sharing can't be high- er than if the services were provided by an in-network physician. 3. Ban on surprise billing for ancillary ser- vices and any "others." e rule prohibits providers from charging out-of-network rates for ancillary care in in-network facilities in all instances. is includes anesthesiology ser- vices. CMS said that it also includes a ban on any other out-of-network charges to patients without notice. 4. Ban on retroactive emergency depart- ment denials. CMS' proposed surprise-billing rule would prevent insurers from retroactively denying emergency department claims. CMS said in the rule that it is aware that some plans currently deny coverage provided in hospital EDs if the claim is considered nonemergent based "soley on final diagnostic codes." 5. Interim payment or notice of denial from insurers. e interim final rule would require health plans to make an initial payment or is- sue a notice of denial to providers in 30 days aer it receives a clean claim. 6. Consent process to waive balance-billing protections. e rule would allow patients to waive their balance-billing protections and consent to out-of-network charges. e rule directs the departments to establish a process to obtain patient consent for balance billing. Providers can't use this for emergency ser- vices or some ancillary services. 7. Providers must disclose balance-billing protections. Providers will be required to publicly post or inform patients about sur- prise-billing protections. 8. Qualifying payment amount. CMS de- fined the qualifying payment amount, which will calculate patient cost-sharing and be used by an arbiter in the independent dispute res- olution process, as the issuer's median in-net- work rate for 2019 trended forward. e rule addresses several factors that will determine how the rates are set, including the type of contract, insurance market, geographic region and rates for same or similar services. 9. Complaint process. rough the pro- posed rule, CMS will establish a process for which patients and others can submit complaints about violations of the balance- billing requirements. n $450M for New Jersey's level 1 trauma centers leaves execs stunned By Molly Gamble N ew Jersey stakeholders were stunned to see $450 million allotted in the governor's final budget for the state's three level 1 trauma cen- ters to strengthen emergency preparedness, Politico reported July 2. Those three trauma centers are University Hospital in Newark, RWJBarnabas Health's Robert Wood Johnson University Hospital in New Brunswick and Cooper Uni- versity Health in Camden. Gov. Phil Murphy's fiscal year 2022 budget reflects some of the first allocations of the federal American Rescue Plan's State Fiscal Recovery Fund, or SFRF, dol- lars to bolster New Jersey's public health infrastructure and ensure readiness for the next emergency. Politico reported that the allocation left healthcare lob- byists, healthcare executives and lawmakers "stunned," with University Hospital President and CEO Shereef El- nahal, MD, noting he was "floored" when he saw his fa- cility could receive up to $150 million in SFRF funds. n HCA trauma activation fees far exceed rivals, KHN finds By Morgan Haefner N ashville, Tenn.-based HCA Healthcare's average activation fees at its trauma centers can be up to 10 times higher than those at non-HCA hospitals, according to Kaiser Health News. Trauma centers have become part of HCA Healthcare's growth strategy, corporate officials have said, according to a June 14 KHN report. The hospital operator has trauma cen- ters in more than half of its 179 hospitals. Publicly posted price lists show HCA Healthcare's trauma activation fees can be up to $50,000 per patient. In Califor- nia, for example, the average trauma activation fee for HCA is $38,804, compared to an average non-HCA charge of $18,253, according to 2020 data cited by KHN. In a statement to KHN, an HCA spokesperson said, "Fees as- sociated with trauma activation are based on our costs to im- mediately deploy lifesaving resources and measures 24/7." Patients' out-of-pocket costs depend on their insurance plan, and uninsured and low-income patients often don't pay any- thing for trauma services, the spokesperson added. n

• Cover