Relief from surprise billing?

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HHS and CMS have approved a new rule eliminating balance billing by certain providers starting in 2022. Balance billing is when an Out of Network (OON) provider may bill the individual for the difference between the charge and the amount paid by their plan or insurance, unless prohibited by state law. A recent study found that payments made to providers/facilities by people who got a surprise bill for emergency care were more than ten times higher than those made by other individuals for the same care.

Additionally, (OON) cost sharing and surprise bills usually do not count toward a person’s deductible and maximum out-of-pocket limit.

On July 13, 2021, the Departments and OPM issued “Requirements Related to Surprise Billing; Part I,” a rule that will restrict excessive out-of-pocket costs to consumers resulting from surprise billing and balance billing. This rule goes into effect for health care providers and facilities, and providers of air ambulance services on January 1, 2022, and for plan, policy, or contract years starting on or after January 1, 2022, for group health plans, health insurance issuers, and Federal Employees Health Benefits (FEHB) program carriers. It will ban balance billing for emergency services. Cost-sharing for emergency services must be determined on an in-network basis.

This will prohibit (OON) charges for items or services provided by an (OON) provider at an in-network facility, unless certain notice and consent is given.

The rate for this cost sharing is calculated based on a state All-Payer Model Agreement, specified state law, or, if neither of these apply, the qualifying payment amount (QPA). The QPA is generally the plan or issuer’s median contracted rate for the same or similar service in the specific geographic area.


We continue to see more advances with respect to Medicare and new treatments. Please watch this space as updates happen.

Our Editorial Note: Above is our summary of a recent update on Medicare, it is not meant to be complete or show the entirety of changes. Contact us if you would like to learn more about regenerative medicine and how it may help patients with Covid-19 and other medical conditions.


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