American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

CMS urged to extend enforcement discretion for No Surprises Act requirement  | AHA News

Source: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.

WHAT’S THE IMPACT

Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.

THE LARGER TREND

In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

American Hospital Association Urges CMS To Extend Enforcement Discretion For No Surprises Act

3.2% payment increase is not enough, American Hospital Association says |  Healthcare Finance NewsSource: Healthcare Finance, by Jeff Lagasse

The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion for the No Surprises Act regulatory requirement that healthcare providers exchange certain information to create a good faith estimate for uninsured and self-pay patients – until the agency identifies, and providers can implement, a standard, automated way to exchange the information.

“In the interim final rule implementing this policy, CMS notes that it is exercising enforcement discretion until Jan. 1, 2023, as it may take time for providers and facilities to ‘develop systems and processes for receiving and providing the required information,’” AHA wrote. “We agree that developing and implementing the solution will take time and cannot be achieved efficiently without additional guidance from CMS that identifies a standard technical solution that can be implemented by all providers.”

One of the main concerns from the AHA is that there are currently no methods for unaffiliated providers to share or receive good faith estimates with a convening provider or facility in an automated manner. To share this information, billing systems would need to be able to request and transmit billing rates, discounts and other necessary information for the good faith estimates between providers/facilities.

This is not something that practice management systems can generally do, said the AHA, since billing information is traditionally sent to health insurers and clearinghouses, not other providers.

“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors,” the AHA wrote.

AHA requested an extension in enforcement discretion until a technical solution has been found and implemented.

WHAT’S THE IMPACT

Without an automated standard, the AHA said, providers would need to determine individually how to transmit the information. That in turn could lead to variance throughout the industry, especially considering differences in size and technical sophistication among co-providers and facilities. Navigating a non-standardized process, the AHA contended, would increase administrative burden on providers.

To help work toward a standard solution, The AHA said it’s partnering with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup to discuss potential technical solutions for sharing and receiving critical information among providers. The group will consist of providers and vendors with knowledge of provider systems.

THE LARGER TREND

In December 2021, the American Hospital Association, American Medical Association and other provider organizations sued the Department of Health and Human Services and other federal agencies over implementation of the No Surprise Act. The groups are not against the legislation, they said in the lawsuit filed in federal court but take issue with how HHS implemented a dispute resolution process in the bill.

The No Surprises Act prevented 2 million surprise bills for the commercially insured, according to a survey by AHIP and the Blue Cross Blue Shield Association released in May. The analysis further showed that, if the trend continues, more than 12 million surprise bills would be avoided in 2022.

Commissioner Urges DOJ to Block Anthem/Cigna Merger

CIGNA-AnthemMerger

California Insurance Commissioner Dave Jones is urging the Dept. of Justice to block the merger of Anthem and Cigna. The merger, which is estimated to be worth more than $50 billion, would make Anthem the nation’s largest health insurer. Anthem’s market share would exceed 50% in 28 California counties and 40% in 38 counties. Jones said that the merger would reduce access to quality care, and reduce health insurance affordability. Under California law, the commissioner does not have direct approval authority over the Anthem and Cigna merger since Cigna is domiciled in Connecticut.

At a public hearing on March 29, Anthem executives claimed that the merger would result in $2 billion in savings. But Jones said that Anthem provided only vague and speculative assertions when asked to back up that claim. At the hearing, Anthem would not commit to pass any savings onto consumers through lower prices.

Jones said, “More competition in California’s consolidated health insurance markets is needed, not less. Competition helps restrain prices, provides choice, and improves quality. The Anthem and Cigna merger reduces competition in a market that is already dominated by just four health insurers. It will likely result in reducing consumers’ choices, increased prices, and lower quality care,” he said. Jones provided the following statistics about California in 2014:

  • The four largest insurers controlled 85% of the market.
  • Four insurers controlled 82% of the large group market statewide.
  • Four insurers controlled 88% of the small group market.
  • Four insurers controlled 93% of the individual market.
  • In Covered California, the four largest plans controlled 95% of the individual market in 2014 and 91% of the market in 2015.

Covered California Urges Federal Officials to Consider Standard Benefit Design and Robust Marketing

Covered California executive director, Peter Lee, gave HHS some suggestions on running a successful Marketplace. Covered California submitted written comments in response to proposed federal regulations. Covered California weighed in on three key elements, related to establishing a standard benefit design, ensuring that federal and state exchanges have resources to do effective marketing, and defining the role of Web-based entities in enrollment.

Standard Benefit Design
Proposed regulations related to the federal marketplace in 2017 contemplate the standardization of benefits under the Affordable Care Act. Covered California offers standardized benefits so that consumers can easily compare health insurance plans knowing that every plan within the same metal tier has the same cost-sharing amounts and benefits. With standardized benefits, consumers know that some services will always be affordable and accessible. For example, every health plan available through Covered California has primary care visits that are not subject to the deductible, which means that primary care is affordable and accessible.

Federal Assessment on Plans to Ensure Ongoing Enrollment
Recent reports from HHS, California, and other states’ exchanges show that enrollment for the upcoming third coverage year of the Affordable Care Act is strong, which bodes well for continued improvement of the risk mix and long-term affordability. The proposed federal regulations, which would not take effect until 2017, present the assessment on health plans to support all marketplace functions, including a small portion for marketing and outreach costs. While California has no plans to use the federal enrollment platform, Covered California says that marketing and outreach is vital to promoting larger enrollment and retention by encouraging healthier consumers to buy health insurance. This fosters a better risk mix that keeps premiums low for the entire market.

Web-Based Entities
Covered California says that having clear standards and expectations of Web-based entities’ is critical. Without clear standards, consumers may experience confusing displays of health plan options, make less optimal plan and product choices, be routed to off-exchange products, or not get appropriate in-person support when it is needed. Having poor or confusing plan choice display runs the risk of smaller enrollment and a worse risk pool. Covered California says that Web-based entities and other direct enrollment vendors should have to support consumers in all aspects of the application, display available health plans with additional consumer tools such as filtering and sorting options, and meet other requirements. 

Covered California Experiences Record-Breaking Enrollment
Covered California announced that more than 197,000 consumers had enrolled in health care coverage by the end of Tuesday, Dec. 15, including more than 22,000 on Monday and more than 32,000 on Tuesday. The two-day total of more than 55,000 surpassed the enrollment figures seen last year during the same two-day period when more than 35,000 people signed up for coverage on December 14 to15, 2014.

Broad Coalition Urges California to Fully Fund Medi-Cal

We Care for California,” a broad coalition of doctors, nurses, hospitals, workers, and other healthcare leaders, launched a media campaign calling on California to make Medi-Cal providers payments in line with Medicare rates.

The eight-week campaign kicks off a sustained effort to help Californians and state leaders understand how severe underfunding of Medi-Cal harms millions of children, seniors in nursing homes, pregnant women, and people with disabilities, all of whom have difficulty getting access to the healthcare.

The campaign includes English and Spanish TV, radio, direct mail, outdoor billboards, and online calls ads. The TV ads are running in Los Angeles, San Francisco, San Diego, and Sacramento. A selection of TV advertisements can be viewed on www.Medi-CalMatters.org.

More than half of California children rely on Medi-Cal for basic healthcare, as do two-thirds of the state’s nursing home patients. But today, Medi-Cal is critically underfunded, preventing millions from getting quality healthcare or even getting an appointment with a health provider.

The coalition is seeking passage of two bills, SB 243 and AB 366, which would fully fund Medi-Cal. They also want Gov. Jerry Brown to make significant movement toward fully funding Medi-Cal in his May revised budget.  With the chronic underfunding of Medi-Cal, California ranks 48th in the nation in payments to health providers. As a result, 56% of Medi-Cal patients report difficulty finding a doctor, and the severe under-funding costs the state’s hospitals more than $6 billion annually.

“When my son Xavier was suffering from potentially life-threatening allergies, it took more than two months just to see a specialist through Medi-Cal. No child should have to wait months just for basic healthcare, and we have the power to change this and save lives of California children,” said Emily Avila from Cathedral City in Riverside County, who also is featured in the TV ads

Insurance Commissioner Urges Consumers to Challenge Treatment Denials

Insurance Commissioner, Dave Jones, issued a statement urging policyholders to challenge their insurer if the company denies their claims for treatment. He reminds policyholders they have a right to appeal to the company and ask CDI to review the denial. There is also a fair chance a review of the decision could go in their favor.

According to the California Insurance Code, when insurers deny requested treatment as not a covered benefit they are required to give policyholders the specific provisions in their policy that exclude coverage. In addition, if companies deny coverage for a treatment as not medically necessary, they are required to outline the facts and law on which they based their denial.

Jones said, “If your health insurer won’t initially cover your treatment, that’s not the end of it. As a consumer, you have options. You may file a request for assistance with my department whenever you have problems with an insurer involving a claim. Denial by an insurance company is not the final word. If your claim was denied because the insurer determined the treatment is not medically necessary or was experimental, you may request an independent medical review (IMR) from the Department at no cost to you. However, you must first file an appeal of the denial with your insurance company, using the company’s internal appeals/grievance process.”  For more information, visithttp://www.insurance.ca.gov/0100-consumers/0020-health-related/0020-imr/upload/

HCB002IMR.pdf

Last Updated 06/29/2022

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