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Patient protections under the Centers for Medicare and Medicaid Services

Lia Cirelli and Lila Kelso


October 28th, 2021

Patient protections under the Centers for Medicare and Medicaid Services

Amidst the COVID-19 pandemic, the Centers for Medicare and Medicaid Services have made a number of updates to mandates that will impact payers and providers alike. As Avant-garde Health continues to work with clients to ensure that value-based care is implemented across enterprises, ensuring that organizations remain in line with requirements from CMS will be of utmost importance. At the 2021 Becker’s Healthcare Payer Issues Virtual Summit, panelists outlined the three largest takeaways:

  1. CMS’s No Surprises Act will shield patients from unexpected costs.

Under this rule, commercial payers will be required to put limits on unexpected additional costs incurred to patients. This will essentially create a “shopping” experience for patients, helping them to understand what they can anticipate when engaging in medical care. Included in this is, “limiting the surprise cost of an out-of-network provider to an in-network facility.” Patients will also be shielded from paying for some emergency services from out-of-network providers, emergency air ambulance bills, and balanced billing. Patients will also be able to receive an explanation of benefits that estimates expected charges and out-of-pocket expenses. If services sought by the patient are out-of-network, payers must provide how one might obtain in-network coverage.

The No Surprises Act also seeks to protect those who do not have health insurance. Under the Act’s good-faith estimate stipulations, health care providers have to provide an estimate of expected charges to both uninsured and insured patients who do not plan to use insurance to cover care. The estimate has to be provided after a medical procedure has been booked and must include all component parts of the expected course of care.

  1. Consumers (including those in the private market) will continue to have more access to their healthcare data under upcoming CMS final rules.

As of July 2022, commercial payers will be required to provide an in-network and out-of-network document each month to members that spells out billing-code descriptions, negotiated rates, and additional information for patients to understand the true cost of providing care. This document must be machine-readable to ensure ease of integration with electronic health records. In January 2023, CMS will release an online self-service tool that provides pricing for 500 services, followed in January 2024 list of all items and services. For bundled payments, all services included in the procedure will be listed on these documents, even if the service is covered by a set bundled payment rate.

  1. Patients will have more access to their information under the CMS Interoperability and Patient Access rule.

Mandated to begin on January 1, 2024, the Interoperability and Patient Access rule seeks to make information more rapidly accessible to patients. Organizational members of carve outs such as those engaged in federal and state Medicaid (though not those participating in Medicare Advantage) will be required to adopt application-programming interfaces (APIs) that allow members to more easily use applications to access data, including claims and encounters, clinical data, and active prior-authorization decisions. Included in this would be the patient's ability to review directories of providers, see their pharmacy information, and better manage care. The payer is also required to give the patient the reason for denials when they occur.

Overall, these changes will continue to impact payment structures for medical services provided. Avant-garde Health continuously works with our clients to ensure that the highest quality care is provided at the lowest cost. As more cost transparency is required by CMS, Avant-garde Health’s Care Measurement platform can help health organizations fully understand their cost of providing care, more seamlessly allowing for a transition to a more price-transparent world. Our additional expertise with helping organizations manage their involvement in CMS’s Bundled Payments for Care Improvement Advanced (BPCI Advanced) and can continue to strengthen organizations.

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