Agencies seek feedback on the law's good faith estimating rules with no surprises

Agencies seek feedback on the law’s good faith estimating rules with no surprises

Following closely after the clarification of the Final Rule independent dispute resolution process, the four executive branch entities responsible for implementing the provisions of the law unsurprisingly, the Office of Personnel Management, the Centers for Medicare & Medicaid Services (CMS), the Benefits Security Administration, and the Internal Revenue Service issued a request for information to help agencies develop the next step in surprise billing law regulation.

The request is the latest effort by the agencies to solicit feedback from stakeholders on the contours of regulations implementing the law without surprises, this time focusing on the law’s requirements for providers to issue a good estimate. faith (GFE) to service plans. that their covered patients will submit for reimbursement and for insurers to issue an Advance Explanation of Benefits (AEOB) to their plan participants based on the estimated charges forwarded to them by providers.

Specifically, entities are seeking information and guidance on the process of transferring data from providers and facilities to regimes, issuers and carriers to facilitate the GFE and AEOB processes, as well as the economic impacts of implementing implementation of these requirements. The notice was added to the Federal Register on Friday, September 16, and comments are due to agencies by November 15.

Agencies preparing to define GFE and AEOB requirements

Agencies have already issued regulations implementing aspects of the law without surprises, but those earlier regulations have delayed enforcement of the GFE and AEOB provisions for insured patients. These deferrals were made in response to stakeholder requests for agencies to develop data transfer standards and to give industry time to put in place the necessary infrastructure to make these transfers. For more information on the old No Surprises Act rules and GFEs in particular, check out these previous articles on the subject.

The No Surprises Act requires providers and facilities to pass cost estimates to patients, either directly through a GFE for uninsured patients, or indirectly for insured patients through estimated costs passed to health plans and health care providers. insurers who will then issue an AEOB. The law also requires health care providers and facilities to issue an EFG to health plans and insurers for procedures that those covered by the plans will later submit for reimbursement.

Focus is on interoperability and data security

To facilitate the required information transfers needed for GFEs and AEOBs, CMS began testing an approach that could support the level of interoperability that would be required to implement these data transfers. For comment, the proposed approach is based on the Health Level 7 Fast Healthcare Interoperability Resources (FHIR) standard and includes the deployment of an application programming interface (API) that would enable real-time data exchange AEOB and GFE. These standards should sound familiar to those focused on implementing the interoperability rules promulgated by CMS and the Office of the National Health Information Technology (ONC) Coordinator in 2020.

In their request for comment, the agencies asked interested parties to share considerations to take into account when evaluating whether to opt for the FHIR-based API approach. As a primary consideration, the agencies note that HIPAA’s privacy and security rules apply to the data at issue here, even though this type of pricing data is not included in the type of data covered by the requirements. administrative simplification of HIPAA, and invite comments on whether the proposed approach sufficiently protects data protected by HIPAA. In addition to soliciting feedback on privacy concerns they should consider when developing these standards, the agencies are also seeking feedback on barriers to implementing the standards as well as flexibilities. who could overcome these barriers and help with implementation.

Other policy considerations included

The announcement also seeks comments on other policy considerations related to GFEs and AEOBs. For example, agencies seek information on how non-participating providers who provide non-emergency services enforce the GFE requirement and whether those providers may seek patient consent to waive the law’s protections in the process. part of their GFE transfer.

There are also questions about how much notice providers must give to plans they seek consent to waive the law’s protections of balanced billing and cost-sharing and what would constitute sufficient notice and notice of waiver.

The opinion includes a number of other policy considerations, including questions about how the AEOB should be presented to patients and how the data that is transmitted should be presented to the patient.

Finally, the agencies seek information on the economic impact of the implementation of the GFE and AEOB rules on the industry, as is common in such information requests.

Comments must be submitted to agencies by 5 p.m. on November 15, 2022.

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