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The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) recently announced it would conduct a “nationwide audit to determine whether hospitals that received PRF payments and attested to the associated terms and conditions complied with the balance billing requirement for COVID-19 inpatients.” They also indicated a final report on the PRF balance billing compliance is expected to be issued by the OIG during 2023.

Approximately $178 billion in Provider Relief Fund (PRF) payments were appropriated to healthcare providers through the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), Paycheck Protection Program and Health Care Enhancement Act, and 2021 Consolidated Appropriations Act. In order to accept these payments, eligible healthcare providers were required to attest to specific terms and conditions, including a requirement that eligible healthcare entities “will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network recipient” for all presumptive or actual cases of COVID-19. 

According to HHS, this is the result of the capacity constraints many healthcare providers are experiencing during the COVID-19 public health emergency. This may not allow for patients to choose to receive all care from in-network healthcare providers, necessitating they seek care instead from an out-of-network provider. According to the OIG, they “will assess how bills were calculated for out-of-network patients admitted for COVID-19 treatment, review supporting documentation for compliance, and assess procedural controls and monitoring to ensure compliance with the balance billing requirement.”  

This requirement is similar to the regulations outlined in the No Surprises Act, which prohibits surprise balance billing for emergency services and nonemergent care provided by out-of-network providers at in-network facilities and requires payors and providers to support in-network cost share amounts for such encounters. The No Surprises Act went into effect January 1, 2022.

Questions remain, however, about the requirement in the terms and conditions, how this would be tested in a single audit as well as how it will be audited by OIG in light of HHS’s recent announcement.  Of particular uncertainty is how a provider would know what an out-of-network patient’s out-of-pocket expenses would have been if they would have seen an in-network provider.   

Healthcare entities should review their policies and procedures to assess whether safeguards are in place to help prevent balance billing of presumptive and actual COVID-19 patients and compliance with the No Surprises Act. Healthcare entities should continue to monitor for any additional clarifications from HHS on how requirements should be met.

A final report on the PRF balance billing compliance is expected to be issued by the OIG during 2023.

For questions, or to discuss the PRF balance billing terms and conditions or the No Surprises Act in more depth, please consult your BKD Trusted Advisor™ or submit the Contact Us form below.

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