Graphic courtesy of The American College of Radiology

Graphic courtesy of The American College of Radiology 


September 6, 2022 — On Aug. 19, the Departments of Labor, Health and Human Services (HHS), and the Treasury (“the Departments”) issued the Requirements Related to Surprise Billing: Final Rules. This set of rules is narrow in scope and only addresses the payment determination standards under the Federal independent dispute resolution (IDR) process and “downcoding” of claims by insurers. The American College of Radiology (ACR) has developed a detailed summary of the final rules

The final rules direct certified IDR entities to select the offer that the IDR entity determines “best represents the value of the qualified item or service as the out-of-network rate.” The rules indicate that the qualifying payment amount (QPA) or median in-network rate is no longer presumed to be the most appropriate out-of-network rate. The rules then state that the IDR entity must first consider the QPA for the same or similar item or service and then must consider additional “credible” information submitted. IDR entities must provide explanations for every decision. However, if the IDR entity selects an amount that is not the QPA, it must explain what other credible information was considered and why those factors are not already accounted for in the QPA calculation. 

The final rules also address “downcoding,” defined as “the alteration by a plan or issuer of a service code to another service code, or the alteration, addition, or removal by a plan or issuer of a modifier, if the changed code or modifier is associated with a lower QPA than the service code or modifier billed by the provider, facility or provider of air ambulance services.” The rules require insurers that downcode claims to provide a statement that the service code or modifier billed by the provider, facility or provider of air ambulance services was downcoded; an explanation of why the claim was downcoded, including a description of which service codes were altered, if any, and which modifiers were altered, added or removed, if any; and the amount that would have been the QPA had the service code or modifier not been downcoded. 

The Consolidated Appropriations Act, 2021 (CAA), including the No Surprises Act (NSA), was enacted on Dec. 27, 2020. The NSA provides federal protections against surprise billing and limits out-of-network cost sharing under many of the circumstances in which unexpected bills arise most frequently. “Surprise billing” occurs when an individual receives an unexpected medical bill from a healthcare provider or facility after receiving medical services from a provider or facility that, usually unknown to the participant, beneficiary or enrollee, is a nonparticipating provider or facility with respect to the individual’s coverage. 

For more information: www.acr.org 

 

Related content: 

CMS Withdraws Guidance on Surprise Billing, Out-of-Network Payment Disputes 

ACR Joins "No Surprises Act" Lawsuit to Protect Patient Care 

Major Medical Associations Ask Federal Court for Summary Judgement in No Surprises Lawsuit 

Radiation Oncologists Applaud Biden-Harris Administration's Renewed Commitment to Cancer Moonshot   

Racial/Ethnic Disparities Persist in Lung Cancer Screening Eligibility   

Primary Lung Cancers Detected by LDCT are at Lower Risk of Brain Metastases   

Physician and Patient Groups Call On CMS to Update Medicare Lung Cancer Screening Coverage   

USPSTF Expands Lung Cancer Screening Eligibility Thresholds    

Low-dose CT for Lung Cancer Screening: Benefit Outweighs Potential Harm   

Physician and Patient Groups Call On CMS to Update Medicare Lung Cancer Screening Coverage   

 


Related Content

News | Artificial Intelligence

July 17, 2025 — HOPPR, a secure AI development platform for medical imaging, has announced the commercial release of its ...

Time July 17, 2025
arrow
News | Breast Imaging

July 17, 2025 — RadNet, Inc., a provider of high-quality, cost-effective diagnostic imaging services and digital health ...

Time July 17, 2025
arrow
News | Focused Ultrasound Therapy

July 15, 2025 — Newswise —The UK Focused Ultrasound Foundation and Pancreatic Cancer UK have announced a new partnership ...

Time July 16, 2025
arrow
News | Radiology Imaging

July 15, 2025 — Radiology Partners (RP), a provider of technology-enabled radiology services, has announced the launch ...

Time July 15, 2025
arrow
News | Digital Radiography (DR)

July 10, 2025 — Fujifilm Healthcare Americas Corp. has launched several advanced automated functions for its FDR ...

Time July 10, 2025
arrow
News | Computed Tomography (CT)

July 01, 2025 — NANO-X Imaging Ltd. recently announced a clinical and educational collaboration with Keiser University ...

Time July 03, 2025
arrow
News | Ultrasound Imaging

June 26, 2025 — FUJIFILM VisualSonics Inc., a provider of ultra-high frequency ultrasound and photoacoustic imaging ...

Time June 27, 2025
arrow
News | Imaging Software Development

June 12, 2025 — GE HealthCare has announced the combination of GE HealthCare’s proprietary features and algorithms with ...

Time June 12, 2025
arrow
News | Radiology Business

The issue of sustainability in healthcare has gained increasing focus over the past several years. During a 2022 plenary ...

Time May 06, 2025
arrow
News | Radiology Imaging

Nov. 13, 2024 — Agfa Radiology Solutions will feature live demonstrations of state-of-the-art digital X-ray rooms ...

Time November 14, 2024
arrow
Subscribe Now