The HHS and Labor Department Aug. 19 issued the final rules for the No Surprises Act.
Here are the three changes that ASCs need to know:
1. The final rule defined the term "downcode" to mean the alteration of a service code to another service code or the removal, addition or alteration of a modifier with a lower qualifying payment amount than the service code billed.
When a qualifying payment amount is based on a downcoded service code or modifier, the issuer or plan must provide the following with its initial payment:
- A statement that the service code or modifier billed was downcoded
- An explanation of why the claim was downcoded, including which codes or modifiers were altered
- The amount the qualifying payment amount would have been had the service not been downcoded
2. Certified independent dispute resolution entities must consider the qualifying payment amount as well as all additional permissible information submitted by each party to choose an appropriate out-of-network rate. After weighing these considerations, independent dispute resolution entities should then select the offer that "best represents the value of the item or service under the dispute."
3. The final rules aso finalized the October 2021 rule requiring certified independent dispute resolution entities to explain payment determinations and underlying rationale in a written decision sent to the HHS and Labor Department. This explanation should include the weight given to the qualifying payment amount.