The Departments of Health and Human Services, Labor, and of the Treasury issued an interim final rule (the “IFR”) concerning the federal No Surprises Act on September 30, 2021. Although the hope was that the IFR would provide clarity as the requirements and dispute resolution programs under the No Surprises Act, it left many questions unanswered and also revealed a considerable hindrance to out-of- network providers securing fair and reasonable reimbursement.

In particular, the presumption that the qualifying payment amount (the “QPA”), defined as the plan’s median in-network rate for the applicable geographic area, serves as the primary obstacle to overcome before fair and reasonable reimbursement will be securable. Notably, this position as set forth in the IFR, contradicts Congressional intent, as explained in the recent letter from the U.S. House of

Representative’s Committee on Ways and Means. Accordingly, prior to delving into how the QPA can be differentiated and, thus, bypassed, this presentation discusses how and why the healthcare industry must unite as one to combat the inequitable guidelines specified in the IFR. In particular, a call to join together to issue unified comment to the aforementioned Departments is issued.

In terms of otherwise bypassing the QPA, the various factors that can be considered are discussed, with explanation as to how these factors can be supported by credible evidence to demonstrate that the QPA is materially different from fair and reasonable out-of-network reimbursements (a requirement set out in the IFR for circumventing the QPA).

Finally, this presentation also discusses, in detail, the requirement to issue good faith estimates to uninsured (or self-pay patients), the questions that remain as related to this process, and the logistics of compliance with the same (a task that will, at least initially, result in a considerable administrative burden, especially in light of the uncertainty as to how the dispute resolution process will play out, as a whole).

Session Objective:

This presentation seeks to address the unfair nature of many of the IFRs guidelines, how the healthcare industry can fight back against this inequity, and how out-of-network providers (namely who provide services at in-network facilities and are subject to the Act’s regulations) can promote the likelihood of securing fair and reasonable compensation.

In addition, this presentation seeks to flesh out the logistics of the provider-plan independent dispute resolution process (“IDR” or the “IDR process”), as failure to properly satisfy the steps therein can prevent full and fair compensation from being secured.

Finally, this presentation will advise providers/facilities as to how they can ensure compliance with the good faith estimate requirements for uninsured and self-pay patients.

Session Agenda:

1. General Information and Perceived Bias in Favor of Plans & Carriers
2. The IDR Process – A Refresher on Timeframes
3. The IDR Process – Open Negotiation
4. The IDR Process – Initiation of IDR
5. The IDR Process – IDRE selection
6. The IDR Process – Submission of Offers
7. The IDR Process – Determinations and Factors
8. The IDR Process – Getting Around the QPA
9. Good Faith Estimates (Generally)
10. Good Faith Estimates – Who is an Uninsured/Self-Pay Patient?
11. Good Faith Estimates – Steps & Requirements
12. Good Faith Estimates – Who’s Responsible?
13. Good Faith Estimates – Deferral to State Law (Open Questions)
14. Topics Not Discussed and Unanswered Questions
15. Key Takeaways

Session Highlights:

1. How the Departments have apparently favored the plans/carriers;
2. The logistics of the IDR process;
3. Factors that can be used to your advantage in the IDR process;
4. How to circumvent the QPA;
5. How the healthcare industry can fight back (actions that can be taken);
6. How to satisfy the good faith estimate requirements; and
7. How the IFR left many unanswered questions / areas where further guidance will still be necessary.

Who will be benefited:

Out-of-network healthcare providers and facility (ambulatory surgery centers, for example) owners and managers.