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Surprise Billing and Protecting Consumers
The Consolidated Appropriations Act of 2021 was established in December 2020 with provisions to protect patients from surprise bills, and it is set to start in 2022. On January 1, consumers will have new billing protections laid out in the No Surprises Act under title I and Transparency under title II. The specific goal is to target unexpected or “surprise” balance bills from air ambulance services and emergency or non-emergency care from out-of-network providers at in-network facilities.
In an emergency situation, when the time or ability to coordinate in-network care is not necessarily an option, it is common for patients to receive care from an out-of-network provider. However, with these new rules, excessive out-of-pocket costs for patients will be restricted, and emergency services must be covered without prior authorization.
Implementing the No Surprises Act
The Biden administration recently released a Second Interim Final Rule to begin the implementation of portions of the No Surprises Act. Specifically, the goal is to help settle out-of-network payment rates as well as provide cost estimates and dispute resolution processes for uninsured patients.
Detailed in the rule, the Independent Dispute Resolution (IDR) process would allow for a type of mediation between parties for irreconcilable issues regarding out-of-network, emergent health coverage for patients. However, IDR entities will operate under the assumption that the qualified payment amount (QPA) is the correct out-of-network amount. The QPA is determined by the insurer’s median contracting rate and not necessarily reflective of real world payment rates.
The AHA has released a statement that they are in support of protections for patients and a balanced experience, but there are concerns that the current interpretation of the No Surprises Act will favor insurance payers over health providers. This rule is still being vetted. Only time will tell if and how it will impact office-based providers.
The Future of Telehealth Coverage with Behavioral Care
At the beginning of the public health emergency (PHE), congress and CMS responded by waiving reimbursement limitations for telehealth services. Earlier this year, amid talks about the purportedly growing mental health crisis in the country, discussions began about the possibility of making the thus far beneficial use of telehealth for mental health a more permanent fixture in care coverage.
The final rule of the CMS 2022 Physician Fee Schedule contains provisions intended to target the expansion of behavioral health care access by utilizing telehealth to eliminate the barrier of proximity to care. Via telehealth services, patients can be evaluated, diagnosed, and even treated for mental health disorders from their homes. Moving forward, Medicare will pay for telehealth behavioral care from rural health clinics and federally qualified health centers in order to expand access for underserved populations.
2022 Physician Fee Schedule Rate Changes
As stated above, CMS has issued its final rule on the Physician Fee Schedule to begin January 1, 2022. The change in rates is one of the most significant portions of this final rule. There is the potential that this rule could be disputed, and alterations may be applied to the fee schedule.
EMB will be providing our individual clinician specialties with a list of some your most commonly utilized procedure codes to highlight the differences between the current fee schedule and this new one. That update will be arriving via the normal method in the coming weeks.
New COVID-19 CPT Vaccine and Immunization Codes
The new vaccine codes for COVID immunizations have been released. The CPT codes are differentiated by vaccine manufacturer and which number injection the patient is at in the vaccine series, including boosters. This will allow providers to more accurately record the care that they are providing. A full list of the new CPT codes can be can be found on the CMS website.
Cost-sharing Waiver Extension with UHC
For the duration of the national PHE, UHC is continuing to waive cost-sharing for in-network and out‑of‑network COVID testing. This applies to Medicare Advantage, Individual Exchange, Individual and Group Market health plans. Medicaid plans have guidelines that are specific to individual states. There are online resources to clear up questions about UHC Medicaid plans in your state, and you can reach out to EMB for assistance with this.
Cigna Updates to Health Care Accommodations
With the extension of the PHE, Cigna has also announced a continuation of its coverage adaptations. The cost-share waiver for COVID testing on Cigna patients now goes to January 15, 2022. Interim credentialing accommodations are extended through the end of the year, and virtual care allowances remain in effect until further notice.
General Updates
- As a reminder, the U.S. saw an increase of COVID cases last winter. The amount of reported COVID cases had been trending down for several weeks; however, numbers appear to be fluctuating a little more, as we move into the holiday season.
- Pfizer has now been given full FDA approval for use in patients age 16 and older. There is also EUA Pfizer approval for patients as young as 5 years old.
- Under the EUA, it is recommended that qualifying immunocompromised individuals seek a booster shot of the original vaccine brand received. This applies to Pfizer, Johnson and Johnson, and Moderna.
- Last year saw a significant decrease in flu cases. Early reports indicate that the respite will not continue for the 2021 – 2022 flu season.
- On November 26, the World Health Organization designated a new strain of COVID. It is being called the Omicron variant, and little is yet known about the transmission rate or severity of symptoms.