HHS to audit balance billing requirements

Balance billing rules were implemented as part of several pieces of COVID-19 aid legislation.

The Department of Health and Human Services (HHS) has announced that it will begin auditing compliance with balance billing rules implemented as part of legislation passed to give aid to practices combatting the COVID-19 pandemic.

According to a news release from the agency, organizations which took funds from the Provider Relief Fund are required to not collect out-of-pocket payments from presumptive or actual COVID-19 patients in excess of what the patient would be required to pay if they were treated in an in-network facility. The national audit will determine whether organizations that received the funds and agreed to the terms complied with the balance billing requirement.

The audit will entail assessing how bills were calculated for out-of-network patients admitted for COVID-19, reviewing supporting documentation for compliance, and assessing procedural controls and monitoring to ensure compliance. A report on the audit is expected in 2023, the release says.

Surprise and balance billing have been a hot topic in Washington as both regulators and legislators have taken aim at the practice that can see patients paying large sums unexpectedly.

In July, HHS released an interim final rule aimed at limiting surprise billing. The provisions included:

  • A ban on surprise billing for emergency services by requiring them to be treated on an in-network basis without prior authorization requirements.
  • A ban on high out-of-network cost-sharing for both emergency and non-emergency care by limiting coinsurance or deductibles from being higher than of the physician were in-network.
  • A full ban on out-of-network charges for ancillary care at an in-network facility.
  • A ban on out-of-network charges without the health care provider or facility providing patients a plain language notice explaining that consent is required to receive out-of-network care before the patient can be billed at the higher rate.

The No Surprise Act went into effect at the beginning of this month. Its primary purpose is to protect patients from surprise medical bills when receiving certain services from – emergency services, non-emergency services from nonparticipating providers at participating facilities, and air ambulance service from nonparticipating providers.