WEDI: HHS No Surprises Act Needs Data Standards to Prevent Burden

In response to the Department of Health and Human Services (HHS) interim final rule implementing provisions of the No Surprises Act, WEDI called for the development of data standards to ensure interoperability of patient health data and prevent administrative burden.

In a letter to the HHS written by Nancy Spector, chair of WEDI, the organization expressed its support of the overall goals of the Act and gave several policy recommendations related to the Good Faith Estimate (GFE) and Advanced Explanation of Benefits (AEOB) provisions.

“The No Surprises Act protects patients from receiving surprise medical bills resulting from gaps in coverage for emergency services and certain services provided by out-of-network clinicians at in-network facilities, including by air ambulances,” Spector wrote in the letter.

The GFE provision requires providers to inquire if a patient is enrolled in a health plan or health insurance coverage upon an individual’s scheduling of items or services. The provider must give a “good faith estimate” of the expected charges for the item or service.

If a patient is enrolled in a health plan and wants to submit a claim, the provider must notify the individual’s plan of the expected charges. Otherwise, the provider must provide the GFE to the individual.

Upon receiving a GFE, the Act requires health plans to send the participant, beneficiary, or enrollee an AEOB notification in understandable language.

WEDI called for HHS to ensure that GFE and AEOB solutions are centered on data standards to ensure interoperability.

“In order for the industry to fully implement the GFE and AEOB requirements and do so in a manner that minimizes administrative burden and cost, the federal government and impacted stakeholders need to come together to develop appropriate solutions,” Spector wrote. “These solutions must have industry support and be standards based.”

WEDI also called for the development of an “implementation glidepath” to aid stakeholders in compliance with the Act.

“Meeting critical provisions of the No Surprises Act, including the GFE and AEOB, will be challenging for industry stakeholders,” Spector noted. “As we have learned from previous national implementations, sufficient time must be allotted for stakeholders to adopt and test new standards and workflows.”

WEDI suggested that HHS put off enforcement of federal GFE and AEOB provisions until stakeholder education and testing have been completed.

“Education should be targeted at providers and health plans to assist in compliance efforts,” Spector wrote. “As the industry seeks to identify and implement solutions to meet the requirements of the No Surprises Act, we urge the federal government to partner with WEDI to convene key stakeholders and deliver much-needed education.”

The interim final rule requires a GFE and AEOB for every scheduled service, which could lead to administrative burden for health plans and providers, WEDI noted. To avoid that workload, the organization suggested that the patients initiate requests for GFEs or AEOBs.

In many cases, patients know what their expected out-of-pocket costs will be, which eliminates the need for an AEOB, WEDI said.

The organization also noted that sending GFE and AEOB notifications for every service could confuse patients. A patient receiving an AEOB might believe that the document is a bill she needs to pay. This confusion could be exacerbated by the fact that the AEOB will arrive prior to the service date, WEDI noted.

“We anticipate that calls from patients to their provider and/or health plan asking for clarifications will climb sharply,” Spector wrote.

The organization also noted the importance of implementing a comprehensive patient educational program to outline the new rights the Act provides.

“In order for patients to become aware of these new rights and take full advantage of these rights, the federal government should conduct a comprehensive educational campaign aimed at patients,” Spector wrote.