1/ In the "section by section" summary, several key #SMB changes from the 12/11/20 draft appear to have been made (subject to seeing leg. language): 1. the median in network rate must be "market based" instead of unilaterally determined by the health plan (++); 2. gov't payors...
2/ "public payor rates" cannot be considered by the adjudicator, & not charges (that was in the earlier draft); 3. Not sure if the tech. issues w/ claims that occur during the IDR being eligible for the next IDR were addressed--seems like they're trying to there; 4. stay tuned
3/ "trying to get there"... if I had a nickel for every typo in the past month....
4/ The bottom line--this bill--subject to seeing the actual language--is WAY better than the E&C bill in the Spring of '19 & later the Pallone/Alexander compromise--so all you advocates out there--maybe you doubted "that 1 doctor could make a difference"--feel good that u did!!!
5/ more positive changes we’ve sought—5. Changed that the health plan had to “respond” (12/11/20 version) to a claim for payment to that they have to make an “initial payment or notice of denial” (state prompt pay laws would help here but ERISA plans might claim exemption) ....
6/ the “2 calendar day notice” period 4 physicians has been > to 4 days, better but not optimum—more later—new bill adds >100 pages to a nearly 400 page bill. So #SMB is plus 500 pages & the total Omnibus has be well in excess of 2-3K pages—maybe 4-5k? And members will know it?
7/ More potential good news as we delve into the bill--and 2021 rule makine will be critical--the Sec. of HHS will have discretion to modify both deadlines & timing requirements re: the 90 day colling off period, e.g. for small group practices, & that all claims pre....
8/ IDR decision are permitted into the next IDR after the 90 day cooling off period (note the typo above uugghgg) as follows:
1.‘(9) WAIVER AUTHORITY.—The Secretary may
2.10 modify any deadline or other timing requirement
3.11 specified under ......
1.‘(9) WAIVER AUTHORITY.—The Secretary may
2.10 modify any deadline or other timing requirement
3.11 specified under ......
9/ this subsection (other than the es-
4.12 tablishment date for the IDR process under para-
5.13 graph (2)(A) and other than under paragraph (6))
6.14 in cases of extenuating circumstances, as specified
7.15 by the Secretary, or to ensure that all claims that ....
4.12 tablishment date for the IDR process under para-
5.13 graph (2)(A) and other than under paragraph (6))
6.14 in cases of extenuating circumstances, as specified
7.15 by the Secretary, or to ensure that all claims that ....
10/ 8.16 occur during a 90-day period described in paragraph 17 (5)(E)(ii), but with respect to which a notification is 18 not permitted by reason of such paragraph to be 19 submitted under paragraph (1)(B) during such period, are eligible for the IDR process.’’.
*rule making*
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