On July 1, the U.S. Department of Health and Human Services (HHS) issued a new interim final rule protecting patients from "excessive" out of pocket costs due to surprise and balance billing. With two-thirds of bankruptcies in the United States attributed to medical expenses – and one in every six emergency room visits and inpatient hospital stays involving care from at least one out-of-network provider – surprise medical billing has devastating consequences for Americans and their families.

While prohibitions already exist for balance billing in both Medicare and Medicaid, this rule will extend similar protections to Americans insured through commercial and employer-sponsored health plans.

Key provisions of the interim final rule will now prohibit:

• Surprise billing for emergency services and requirements for prior authorization of emergency services, regardless of where they are provided;
• High out-of-network cost-sharing for emergency and non-emergency services;
• Patient cost-sharing, such as co-insurance or a deductible, that are higher than if such services were provided by an in-network doctor (any coinsurance or deductible must be based on in-network provider rates);
• Out-of-network charges for ancillary care, such as for an anesthesiologist or assistant surgeon, at an in-network facility; and
• Other out-of-network charges without advance notice.

Additionally, health care providers and facilities are required to provide patients with a "plain-language consumer notice" explaining that their consent is required should they wish to receive care on an out-of-network basis before the provider can bill at the higher out-of-network rate.

"Financial hardships associated with medical care can have devastating effects on our patients, including causing them to delay care or not take needed medications or even get important procedures," said ACC Health Affairs Committee Chair Samuel O. Jones IV, MD, MPH, FACC. "In medical emergencies, patients often do not have the ability to choose who provides their care. Attempting to navigate the maze of networks created by insurance companies, along with the confusing bureaucracy of hospital billing is frustrating, and gets in the way of our trusted patient-physician relationship. The ACC is committed to protecting patients from unanticipated medical bills and will continue to work with regulators to craft policies that put patients first."

This rule implements the first of several requirements passed in the bipartisan No Surprises Act, which included several provisions informed by the ACC and others in the House of Medicine. Those include a process to determine cost-sharing amounts and set out out-of-network rates, including and an independent dispute resolution (IDR) process. ACC Advocacy is currently analyzing the interim final rule and is planning to provide comments.

The interim final rule will begin to take effect Jan. 1, 2022. Fact sheets on this interim final rule can be found here and here, and its full text can be accessed here. Read through ACC's Health Care Principles and Priorities here to learn about ACC's commitment to promoting practice stability and patient access to affordable care.

Keywords: ACC Advocacy, Deductibles and Coinsurance, Medicaid, Prior Authorization, Bankruptcy, Length of Stay, Inpatients, Health Expenditures, Medicare, Insurance, Health, Cost Sharing, Medicine, Emergency Service, Hospital, United States Dept. of Health and Human Services, Informed Consent, Surgeons

< Back to Listings