Becker's Hospital Review

17 CFO / FINANCE CMS unveils next surprise-billing rule: 12 details By Alia Paavola C MS unveiled Sept. 30 another rule aimed at protecting patients from surprise billing, which addresses several provisions in the No Surprises Act passed by Congress last year. e rule outlines the federal independent dispute resolution process, good faith estimate requirements for uninsured patients, when pa- tient-provider dispute resolution process can be initiated and new exter- nal review provisions. CMS is accepting comments on the interim final rule for 60 days. HHS already released two rules earlier this summer implementing parts of the law. In July, CMS issued the first part of the suprise-billing rule, which discussed consumer protections from balance billing and out- lawed retroactive emergency department denial policies. On Sept. 10, CMS issued a notice of proposed rule-making that would change report- ing requirements for air ambulance services and add financial disclosure rules for insurance brokers. e provisions outlined in the Sept. 30 suprise billing rule are effective Jan. 1, 2022. Twelve things to know about CMS' Sept. 30 surprise billing rule: Federal independent dispute resolution process 1. Before initiating a federal independent dispute resolution process, a provider and insurer must start a 30-day "open negotiation" period. If no agreement is reached at the end of the 30 days, either party may initiate an independent dispute resolution process. is must be done within four business days aer the open negotiation period ends. 2. Disputing entities will first have the option to jointly select a certified independent dispute resolution entity to take on the case, but if no mu- tual decision is reached, CMS will select the entity for them. 3. Once an independent dispute resolution entity is selected, the disput- ing parties will submit their payment offers and supporting documenta- tion. is documentation must be submitted 10 business days aer the certified independent dispute resolution entity is selected. 4. e independent dispute resolution entity has 30 business days aer it is selected to take on the dispute to make a payment determination. e entity will select one of the parties' payment offers and must take into account the qualifying payment amount, defined by CMS as the issuer's median in-network rate for 2019, trended forward. 5. Both parties must pay a $50 administrative fee to enter the process. e losing party must also pay a fee to the independent dispute resolu- tion entity. Good faith estimates for uninsured or self-pay patients 6. Providers must furnish a good faith estimate of expected charges to uninsured or self-pay patients. The estimate must include expect- ed charges for all items or services "reasonably expected" to be pro- vided, including services that may be provided at another facility or a different provider. 7. HHS said it will exercise its enforcement discretion, as it "understands that it may take time for providers and facilities to develop systems and processes for providing and receiving the required information from others." Patient-provider dispute resolution 8. A patient's bill is eligible for a dispute resolution process if the patient is billed "substantially in excess" of the good faith estimate and the pro- cess is initiated 120 calendar days aer the patient received the bill. CMS defines "substantially in excess" as billed charges being at least $400 more than the estimate. 9. For the first year, it is $25 to initiate a patient-provider dispute reso- lution process. Becoming a certified independent dispute resolution entity 10. CMS is accepting applications to become a certified IDR entity and will certify entities on a rolling basis. ose that want to be certified by Jan. 1 must submit their application by Nov. 1. 11. Providers, facilities, air ambulance services, health plans and other members of the public can petition for the denial or revocation of certi- fication of an IDR entity. External review 12. CMS expanded the scope of what it can review. In particular, it can now review whether a plan or insurer is complying with the surprise billing and cost-sharing protections under the No Surprises Act. n Walmart names former Highmark exec as health, wellness CFO By Jackie Drees W almart has hired Brian Setzer as its new senior vice president and CFO of Walmart Health and Wellness, a company spokesperson con- firmed to Becker's Aug. 27. Mr. Setzer joins Walmart from Pittsburgh-based High- mark Health, where he most recently served as execu- tive vice president of enterprise planning and opera- tions, according to his LinkedIn account. He also filled various other leadership roles during his time at Highmark, including executive vice president of government markets and senior vice president and CFO. Mr. Setzer also served as CFO of Cigna before joining Highmark. In July, Walmart named pharmaceutical industry veteran John Wigneswaran, MD, as its new CMO. The retail com- pany has taken several steps to expand its healthcare presence, including opening medical clinics, acquir- ing telehealth company MeMD and rolling out its own brand of insulin. n

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