Price Transparency and Surprise Billing

In an effort to promote greater transparency for consumers in health care, Congress, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) and several states have implemented laws and regulations related to price transparency and surprise billing.

Price Transparency – The ultimate goal of price transparency initiatives is to allow consumers/patients to better understand the cost and quality of the health care they receive. At the federal level, rules have been issued requiring hospitals and payors to make standard charges, including negotiated rates and discounted cash prices, publicly available. While controversial, these rules have received bipartisan support and, we predict, will continue in some form, as well as possibly expand over time.

Surprise Billing – When an insured patient receives care from an out-of-network provider, the health plan generally will not cover the entire out-of-network cost. In many cases, the out-of-network provider will bill the patient the difference between their billed charges and the amount paid by the health plan. This is known as “balance billing” or “surprise billing.” Many states have enacted laws to prohibit the practice of balance billing, but such laws are limited in applicability to state-regulated health plans and do not apply to health plans governed by the Employee Retirement Income Security Act of 1974 (ERISA). To address this gap and implement a federal “fix” to end surprise billing, Congress enacted the No Surprises Act on December 22, 2020. The Act is intended to bring greater certainty to providers, payors and patients regarding out-of-network reimbursement. The requirements under the Act are to take effect on January 1, 2022.

The No Surprises Act and the Price Transparency Rule are game changers for health care providers and payors alike. Our Price Transparency and Surprise Billing Team can assist with understanding, implementing and complying with requirements including:

• Addressing the complexities of the price transparency and surprise billing requirements;
• Assessing strategies for compliance with the requirements;
• Understanding the risks and penalties related to compliance with the requirements;
• Responding to audit findings and media inquiries; and
• Monitoring state-level legislative and regulatory requirements.