Latest News on my Healthcare Radar – Out of Network Costs

CMS bans Surprise Billing

The issues here were medical services practitioners not being on hospital staff. Practitioners not subject to hospital billing practices and bargaining contracts with Healthcare insurance were billing at their rates to recover what they deem to be reasonable. In the end, the patient pays whatever can be worked out. Radiology and Anesthesiology are two of the practices which come to mind.


The Biden administration on Thursday unveiled the first in a series of rules aimed at banning surprise billing.

The interim final rule bans surprise billing for emergency services and high out-of-network cost-sharing for emergency and non-emergency service. The bill also prohibits out-of-network charges for ancillary services like those provided by anesthesiologists or assistant surgeons, as well as other out-of-network charges without advance notice.

HHS Secretary Xavier Becerra said in a statement: “No patient should forgo care for fear of surprise billing. Having health insurance should be offering patients peace of mind of not incurring unexpected costs. The Biden-Harris Administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises.”

CMS bans surprise billing, Modern Healthcare, Michael Brady, July 1, 2021

Among other provisions, today’s interim final rule:

  • Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
  • Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
  • Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
  • Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice requiring consent to treatment before out-of-network care. A provider can bill at the higher out-of-network rate then if patient agrees.

These are interim rules. It is a start and shy of Single Payer (the better alternative) or Med4All. Still no controls on costs other than informing patients.

More on this later.