Blog

On February 23, 2022, a Federal Court in Texas issued a decision and final judgment that certain parts of the Interim Final Rules Part II (“Rules”) adopted under the No Surprises Act (“NSA”) are invalid.  Specifically, the Judge held that the “presumption” that the Qualifying Payment Amount (QPA) is the appropriate out-of-network rate, unless credible […]

The federal No Surprises Act (NSA) became effective January 1, 2022. The law is designed to protect patients from unexpected medical bills arising from emergency and most non-emergency services administered by out-of-network providers in certain settings, and it prohibits providers from balance billing patients under these circumstances.  It also protects patients from paying more than […]

The No Surprises Act (NSA) took effect January 1, 2022.  This Federal legislation requires out-of-network providers to navigate new rules and adhere to specific timeframes in order to protect their rights to challenge under-reimbursed or denied claims subject to the NSA through negotiations and the Independent Dispute Resolution process. The healthcare industry unanimously agrees that […]

As we welcome in 2022, the much-anticipated federal legislation, the No Surprises Act, has officially gone into effect to protect patients from surprise bills when receiving certain medical services mainly emergency care and non-emergency care services from out-of-network providers at in-network facilities unless notice and consent is obtained prior to the services being rendered. The […]

The NY Department of Financial Services (DFS) recently announced it is amending the NY surprise billing law to “apply federal requirements to the NY IDR process.” As previously reported, in 2020, Congress adopted the No Surprises Act (NSA) which becomes effective for plan years starting on or after January 1, 2022. Under the NSA, out-of-network providers […]

What is the Qualified Payment Amount (QPA) and why is there so much controversy surrounding the interim rules announced by the departments with regard to its application in the Independent Dispute Resolution (IDR) process under the No Surprises Act? As previously written about, the No Surprises Act (NSA) goes into effect for virtually all health […]

As previously indicated, several lawsuits have been filed challenging the rules under the No Surprises Act regarding the presumption for Independent Dispute Resolution (arbitration) that the Qualified Payment Amount (QPA), the median in-network contract rate, is the proper reimbursement for out-of-network services covered under the No Surprises Act. On December 9, 2021, a new lawsuit […]

Concerns About the Federal No Surprises Act: Interim Final Rules According to an article published by KHN, the federal agencies responsible for issuing the regulations for the implementation of “the No Surprises Act” (NSA) have publicly acknowledged that the concerns raised by legislators, providers and medical associations over the federal legislation have been heard. However, […]

For years, insurance companies have operated networks of physicians and facilities which they pair with company benefit plans and their own insurance policies to facilitate “in-network” coverage for members.  Physician networks are marketed by insurance companies to providers on the basis that joining a network will bring increased volume to the practice at a discount […]

The Women’s Health and Cancer Rights Act (WHCRA), passed by Congress in 1998 and adopted as part of the Employee Retirement Income Security Act (ERISA), was enacted to protect women from abuses related to health plan coverage for a mastectomy and breast reconstruction following a mastectomy. The Act requires that any group health plan providing […]

The Departments of Health & Human Services (HHS), Labor, and the Treasury together with the Office of Personnel Management (OPM) issued, on September 10, 2021, a second set of regulations under the No Surprises Act (NSA). The proposed rule outlines the audit and enforcement actions that apply to insurers, healthcare providers and facilities for non-compliance […]

At face value, it seems logical that insurance companies are responsible for paying health benefit claims. But are they? Determining the entity responsible for paying claims requires an understanding of how health benefit plans are structured and governed. In the US, most private-sector employers offer employees the opportunity to participate in a health benefit plan: […]