番茄社区

WASHINGTON -- Doctors and medical practices are cheering a decision by the Biden administration to delay enforcement of a rule requiring physician practices to send patients an "advanced Explanation of Benefits" (advanced EOB) prior to performing a test or procedure.

The advanced EOB requirement, part of the "No Surprises" Act transparency rule passed earlier this year by Congress, is designed to give patients advance notice of how much they likely will have to pay out of pocket for a particular test or procedure. As the administration explains on page 6 of , which was issued on August 20, "The notification must include: (1) the network status of the provider or facility; (2) the contracted rate for the item or service ... (3) the good faith estimate received from the provider; (4) a good faith estimate of the amount the plan or coverage is responsible for paying, and the amount of any cost-sharing for which the individual would be responsible for paying ... and (5) disclaimers indicating whether coverage is subject to any medical management techniques."

The rule was set to take effect in January 2022. However, "the Departments [of Labor, Health and Human Services (HHS), and the Treasury] have received feedback from the public about the challenges of developing the technical infrastructure necessary for providers and facilities to transmit to plans and issuers, starting January 1, 2022, the good faith estimates required," the FAQ says. "Stakeholders have requested that the departments delay the applicability date of this provision until the departments have established standards for the data transfer between providers and facilities and plans and issuers and have given enough time for plans and issuers and providers and facilities to build the infrastructure necessary to support the transfers."

"The departments agree that compliance with this section is likely not possible by January 1, 2022, and therefore intend to undertake notice and comment rulemaking in the future to implement this provision, including establishing appropriate data transfer standards," according to the FAQ. "Until that time, the departments will defer enforcement of the requirement that plans and issuers must provide an Advanced Explanation of Benefits. However, HHS will investigate whether interim solutions are feasible for insured consumers. HHS encourages states that are primary enforcers of this requirement with regard to issuers to take a similar enforcement approach."

The Medical Group Management Association (MGMA), which represents physician practices, praised the decision to delay enforcement. "While we appreciate the intent of this provision is to increase transparency, the reality is it will do little to help patients understand the true cost of healthcare," Anders Gilberg, MGMA senior vice president for government affairs, said in an email (Disclosure: Gilberg is a member of the 番茄社区 editorial board.) "Medical groups typically do not know what services they will bill for until they see the patient, unless it's a discrete procedure or diagnostic test. To ask them to guess is not only burdensome, but will likely result in an inaccurate accounting of what the patient may owe. An unintended consequence of this requirement could be scaring patients out of seeking treatment due to expensive, incorrect estimates."

The rule also presents operational challenges, he continued. "As demonstrated in other areas such as prior authorization, there is a lack of electronic transaction standards for transmitting information from provider to payer. This is further exacerbated by the short timeframe in which group practices must turn this information around. MGMA is relieved that the departments acknowledged that compliance is likely not possible by Jan. 1, 2022 and will defer enforcement. This will give the provider community time to develop a more workable solution via rulemaking, or go to Congress to seek an intervention."

The American Medical Association (AMA) also was happy with the move. "The AMA is pleased [the administration] recognizes the challenges of implementing this provision, and we look forward to working with the agency to ensure that this additional time is used to find a standardized process to provide meaningful cost information to patients and physicians," the association said in a statement. "January 1 was not a feasible deadline by which to implement the provision effectively in a way that would support a uniform process for all insurers. With additional time, participants can figure out the technology so the good faith estimates/advanced EOBs can be requested and sent in a standard way across health plans."

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