How to Pursue Standardization in Surprise Billing Compliance
CAQH members largely agreed that pursuing a uniform approach to surprise billing compliance will be critical to reducing instances of surprise billing.
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- Surprise billing is a burden on patients and healthcare stakeholders alike, but the healthcare industry has had difficulty confronting this problem due to a lack of uniformity.
“Surprise billing happens when people unknowingly get care from providers that are outside of their health plan's network and can happen for both emergency and non-emergency care,” the Department of Health and Human Services (HHS) website explains.
Under the No Surprises Act, which was included as part of the Consolidated Appropriations Act of 2021, patients are not supposed to receive a medical bill when seeking out particular services, Erin Weber, director of the Committee on Operating Rules for Information Exchange (CORE) at the Council for Affordable Quality Healthcare (CAQH), explained on Healthcare Strategies.
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For services that do not fall under this requirement, patients are not allowed to be billed more than their in-network rate unless they give their consent.
As part of these new procedures and regulations, providers have to submit good faith estimates to payers, from which payers create an advanced explanation of benefits.
These changes involve an extensive amount of data exchange as well as reworking or constructing new workflows between providers and payers.
In August 2021, CAQH CORE assembled an advisory group to help assess the barriers that providers and payers face in implementing the regulation and provide guidance on navigating these issues.
The main challenge that the industry faces is that there is no standard for these workflows, even though it applies broadly to two major sectors of the industry—payers and providers. Additionally, many questions still remain unanswered related to what compliance will entail.
“There's a little bit of ‘what comes first, the chicken or the egg?’—should the industry make an assumption around what the regulators want to see or what the intent of the requirements are and address them, or should the industry wait for additional guidance from the regulators?” Weber shared.
“One area where there was clear consensus was that this is definitely an area where we should be focusing on standardization, that if we go down this proprietary route of using portals and, potentially manual processes to exchange this information, it could potentially create a huge burden for the industry.”
Despite these gaps in understanding, Weber had a positive outlook on the overall aims of certain sections of the bill.
“We think that the advanced explanation of benefits workflow really aligns nicely with some of the work that we have already done with CAQH CORE,” Weber said.
In the past, CAQH has established an endpoint directory to support stakeholders’ interoperability compliance.
Going forward, the advisory group will further evaluate areas that of the law that could be standardized and the industry awaits regulatory guidance from CMS and HHS.
