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This interim final rule with comment would implement additional protections against surprise medical bills under the No Surprises Act, including provisions related to the independent dispute resolution processes.

Statement of Need:

Surprise bills can cause significant financial hardship and cause individuals to forgo care.  The No Surprises Act provides federal protections against surprise billing and limits out-of-network cost sharing under many of the circumstances in which surprise medical bills arise most frequently. These interim final rules implement provisions of the No Surprises Act related to the independent dispute resolution process for settling payment disputes and protect individuals from surprise medical bills for emergency services, air ambulance services furnished by nonparticipating providers, and non-emergency services furnished by nonparticipating providers at participating facilities in certain circumstances.

Summary of the Legal Basis:

The Department of Labor regulations are adopted pursuant to the authority contained in 29 U.S.C. 1002, 1135, 1182, 1185d, 1191a, 1191b, and 1191c; Secretary of Labor's Order 1-2011, 77 FR 1088 (Jan. 9, 2012).

Alternatives:

In developing the interim final rules, the Departments considered various alternative approaches, including how to select a certified independent dispute resolution (IDR) entity if the parties fail to do so. The Department considered alternative approaches, including whether the Department should consider the specific fee of the certified IDR entity, or look to other factors, such as how often the certified IDR entity chooses the amount closest to the qualifying payment amount.    

Anticipated Costs and Benefits:

These interim final rules will ensure that consumers are protected from out-of-network medical costs by creating a process for plans and issuers and nonparticipating providers and facilities to resolve disputes on out-of-network rates.  The Departments expect a significant reduction in the incidence of surprise billing, resulting in significant savings for consumers.  There may be a potential transfer from providers, including air ambulance providers and facilities, to the participant, beneficiary, or enrollee if the out-of-network rate collected is lower than what would have been collected had the provider or facility balance billed the participant, beneficiary, or enrollee.  Overall, these interim final rules provide a mechanism to effectively resolve disputes between issuers and providers, while protecting patients.

Risks:

The risk of not pursuing this rulemaking is that group health plans would lack guidance needed to comply with the statutory requirements, plans and health care providers would not be able to resolve payment disputes, and individuals would continue to be burdened by surprise medical bills.