New, Major Regulations Face Providers

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Original story posted on: July 19, 2021

EDITOR’S NOTE:  This story was originally published on RACmonitor July 15, 2021.

By Stanley Nachimson, MS

Some major regulations have been announced in the last few weeks. The departments of Health and Human Services (HHS), Labor, and Treasury announced the first set of rules eliminating surprise billing for commercial health plans. These are interim final rules, meaning they go into effect as written, but the public can provide comments if they wish. They will take effect for healthcare providers and facilities on Jan. 1, 2022. For group health plans, health insurance issuers, and Federal Employee Health Benefits (FEHB) program carriers, the provisions will take effect for plan, policy, or contract years beginning on or after that date.

These rules:

  • Ban surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis, without requirements for prior authorization;
  • Ban high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates;
  • Ban out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances; and
  • Ban other out-of-network charges without advance notice. Healthcare providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

Additionally, this rule requires certain healthcare providers and facilities to furnish patients with a one-page notice on:

  • The requirements and prohibitions applicable to the provider or facility regarding balance billing;
  • Any applicable state balance billing prohibitions or limitations;
  • How to contact appropriate state and federal agencies if the patient believes the provider or facility has violated the requirements described in the notice; and
  • The fact that this information must be publicly available from the provider or facility, too.

This will have a potentially significant impact on the finances of current out-of-network providers, and for health plans. The long-term impact on provider networks is unknown. In regard to coding, it will be critical to identify emergency services when billing.  

Meanwhile, in the Medicare world:

The End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule for the 2022 calendar year (CY) was issued on July 1.  The rule includes changes to rates and policies for CY 2022, and several requests for information (RFIs) similar to those of the prior payment proposed rules.

The proposed CY 2022 ESRD PPS base rate is $255.55, which is an increase of $2.42 to the current base rate of $253.13.

The Centers for Medicare & Medicaid Services (CMS) is proposing to update the acute kidney injury dialysis payment rate for CY 2022 to equal the CY 2022 ESRD PPS base rate, and to apply the CY 2022 wage index. The proposed CY 2022 payment rate is $255.55.

RFIs were issued regarding:

  • COVID-19 vaccination measures;
  • Closing the health equity gap in CMS quality programs; and
  • Future of Digital Quality Measurement.

CMS is also updating its ESRD Treatment Choices (ETC) Model, through which participating ESRD facilities and clinicians who manage dialysis patients (managing clinicians) receive positive or negative adjustments on certain claims for dialysis and dialysis-related services, based on rates of home dialysis and transplantation among their attributed beneficiaries. CMS is proposing changes to the ETC Model to address health and socioeconomic disparities, which are a major contributor to chronic kidney disease and ESRD. The proposed changes include incentives for participating ESRD facilities and managing clinicians to address health equity among their patients. They also include incentives that would reduce the disparities in which ESRD patients of lower socioeconomic status are able to access alternatives to in-center dialysis, specifically home dialysis and transplantation.

If these changes are finalized, the ETC Model would be the agency’s first CMS Innovation Center model to directly address health equity.

CMS also issued The CY 2022 Home Health Prospective Payment System (HH PPS) proposed rule. This rule outlines nationwide expansion of the Home Health Value-Based Purchasing (HHVBP) Model to incentivize quality-of-care improvements without denying or limiting coverage or provision of Medicare benefits for all Medicare consumers, and provides updates to payment rates and policies under the HH PPS.

Additionally, the proposed rule would improve the Home Health Quality Reporting Program by removing or replacing certain quality measures to reduce burden, and increase focus on patient outcomes.

CMS would also begin collecting data on two measures promoting coordination of care in the Home Health Quality Reporting Program, effective Jan. 1, 2023, as well as measures under Long-Term Care Hospital and Inpatient Rehabilitation Quality Reporting Programs, effective Oct. 1, 2022. This would position the agency with data to monitor outcomes across diverse populations and support the recent Executive Order 13985 of Jan. 20, 2021, titled “Advancing Racial Equity and Support for Underserved Communities through the Federal Government.”

Stanley Nachimson, MS

Stanley Nachimson, MS is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption.   The firm serves a number of clients, including WEDI, EHNAC, the Cooperative Exchange, the Association of American Medical Colleges, and No World Borders.  Stanley is focusing on assisting health care providers and plans with their ICD-10 implementation and is the director of the NCHICA-WEDI Timeline Initiative.  He serves on the Board of Advisors for QualEDIx Corporation.

Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions.  His last ten years prior to his 2007 retirement were spent in developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records and serving as the CMS liaison with several industry organizations, including WEDI and HITSP.  He brings a wealth of experience and information regarding the use of standards and technology in the health care industry.