US Patient Groups Give Thumbs-Up to Rule Against Surprise Billing

Surprise billing occurs when patients unexpectedly receive bills for emergency and non-emergency care from healthcare providers outside of their insurance plan’s network.

According to a 2020 study, nearly 20% of insured adults in the U.S. had at least one surprise medical bill from an out-of-network provider in the last two years.

Patients with rare diseases “are particularly vulnerable to the practice of surprise medical billing since a majority of rare diseases have no treatment, leaving many rare disease patients forced to seek emergency care to treat their symptoms,” NORD stated in a 2020 press release.

The new rule will restrict excessive out-of-pocket costs due to surprise bills for Americans insured through commercial and employer-sponsored health insurance plans.

“Our organizations are pleased to see that the interim final rule implements the key patient protections in the No Surprises Act and addresses several areas of concern we recently raised to the Biden administration,” the organizations wrote in the joint statement.

“While we believe additional steps could be taken to strengthen the rule, as written, the rule ensures that patients are held harmless from most surprise bills and protects healthcare affordability and access,” they added. “We look forward to working alongside the administration as it works to implement the No Surprises Act.”

Among other provisions, the rule will ban surprise medical billing for emergency services, which must be treated on an in-network basis. The rule states that health plans cannot retroactively deny coverage for emergency care.

The interim final rule also guarantees that patients do not face higher cost-sharing burdens when a provider bills less than the median in-network rate. Any deductible or co-insurance must be based on in-network rates.

The rule also bans out-of-network charges when patients are treated by care providers who are not covered by the patient’s insurance at an in-network facility.

Furthermore, patient consent is needed to receive out-of-network care before providers can bill at the out-of-network rate. Healthcare facilities must notify patients of this in plain language.

The rule — announced July 1 by the U.S. Departments of Health and Human Services, Labor, and Treasury, along with the Office of Personnel Management — will take effect on Jan. 1, 2022.

“No one should ever be threatened with financial ruin simply for seeking needed medical care,” U.S. Secretary of Labor Marty Walsh said in a press release. “Today’s interim final rule is a major step in implementing the bipartisan No Surprises Act that will protect Americans from exorbitant health costs for unknowingly receiving care from out-of-network providers.”

Apart from NORD, the American Lung Association, the Cystic Fibrosis Foundation, the Hemophilia Federation of America, and the Muscular Dystrophy Association were among the patient and consumer organizations supporting this new rule.

More information about the rule is available on the Centers for Medicare and Medicaid Services’ website.