Health Plan Payment and Reimbursement

News Briefs: A new fee is set for using the No Surprises Act arbitration portal

As published in the February 2024 issue of hfm magazine, a monthly roundup of top news for healthcare finance professionals.

January 30, 2024 11:37 am

Bringing out-of-network payment disputes to arbitration under the No Surprises Act in 2024 will be less expensive than previously proposed.

In a final rule, the U.S. Departments of Health and Human Services, Labor and Treasury established the administrative fee for using the independent dispute resolution (IDR) portal at $115 per case, effective Jan. 22.

That’s down from $150 in the proposed rule issued in September. It’s significantly higher than the $50 rate that was in place going into 2024, but also well under the $350 charge that was implemented without warning for 2023 until August, when the outcome of a lawsuit obligated the departments to revert the fee to $50.

In mid-December, the IDR portal was declared open to all cases for the first time since early August. That’s when a federal-court decision in Texas vacated both the $350 fee and previously published restrictions on batched disputes.

After being closed altogether for the better part of a month, the portal began reopening in phases. But until Dec. 15, batched disputes and air ambulance disputes could not be processed.

Changes coming to regulatory oversight of healthcare M&A

New merger-and-acquisition (M&A) guidelines from the Federal Trade Commission and the U.S. Department of Justice add a wrinkle to the process of consummating deals in healthcare and other industries, especially in the short term as parties adjust to the rules.

The guidance emphasizes that mergers raise a presumption of illegality if they significantly increase concentration in an already concentrated market. The new thresholds for determining the presumption of illegality are a post-merger Herfindahl-Hirschman Index (HHI) score of greater than 1,800, with a projected change of more than 100; or a market share of greater than 30%, with an HHI change of more than 100.

“When exceeded, these concentration metrics indicate that a merger’s effect may be to eliminate substantial competition between the merging parties and to increase coordination among the remaining competitors after the merger,” the guidance states.

For more than a decade, the relevant HHI threshold had been 2,500, with a change of more than 200 indicating an excessive increase in market concentration. The new, lower thresholds mirror those that were in place from the early 1980s until 2010.

House passes bill to codify healthcare price transparency, expand site-neutral payment

The hospital industry saw reason for both relief and disappointment in December when a bill designed to promote price transparency took a major step toward becoming law.

The House of Representatives passed the Lower Costs, More Transparency Act by a 320-71 vote. Along with cementing price transparency as the law of the land for hospitals and other stakeholders, the bipartisan bill would give hospitals a reprieve from a four-year, nearly $32 billion cut to Medicaid disproportionate share hospital (DSH) payments. The cut would be reduced to $16 billion over two years starting in 2026.

But hospital advocates were displeased with the bill’s advancement of site-neutral payment in Medicare. Rates for drug administration services would be reduced in outpatient departments to establish parity with payment for those services as billed by physician offices.

The Federation of American Hospitals wrote to Congress that the proposals on site-neutral payment “would jeopardize access to care and would undermine [the] same safety net” Congress is seeking to support by delaying the Medicaid DSH cuts.

At press time, the bill remained up for consideration in the Senate.

With a new rule, CMS looks to crack down on states’ Medicaid disenrollment processes

In its latest effort to stem the wave of Medicaid disenrollments, CMS issued regulations describing its authority to penalize states for disregarding federal guidelines pertaining to the end of continuous-enrollment requirements.

Published in a December interim final rule with comment period, the regulations took effect immediately. The rule establishes that a state’s federal Medicaid funding will be reduced for each quarter during the period spanning July 1, 2023-June 30, 2024, in which it has not met disenrollment data-reporting requirements.

The reduction will be 0.25% of a state’s federal matching assistance percentage in the first quarter in which the state is noncompliant, then 0.5% in the second quarter, 0.75% in the third quarter and 1% in the fourth quarter.

Furthermore, if a state does not adhere to prescribed processes and criteria for determining disenrollments, CMS can require the state to submit a corrective action plan (CAP). Failure to submit or implement a CAP within the required timeline could result in a mandate to suspend some or all procedural disenrollments and in a penalty starting at $25,000 per day. The rate ultimately could reach $100,000.

CMS offers new coding options for assessing SDoH and more

The final rule establishing the Medicare physician fee schedule for 2024 includes provisions to help clinicians promote health equity by addressing health-related social needs. Most such services also are billable when ordered by facility-based clinicians under the Medicare payment system for outpatient care.

Social determinants of health (SDoH) risk assessments will be billable every six months per patient, including as part of annual wellness visits, evaluation and management (E&M) visits and behavioral health visits. For E&M and behavioral health visits, the assessment is not intended to be a screening but instead should be tied to an SDoH need “that may interfere with the practitioners’ diagnosis or treatment of the patient,” CMS wrote.

New G codes are designed to accommodate payments for community health integration. These payments recognize medically necessary care provided by community health workers during an initiating E&M visit. Covered services include assessments and more.

Principal-illness navigation codes are being expanded to include services furnished by auxiliary personnel such as patient navigators and certified peer specialists to help patients with serious health conditions.


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