You may have noticed that since 2019, the laws and rules related to Price Transparency and Surprise Billing continue to grow and change. What started as one Final Rule defining hospital standard charges has grown to include quite an expansive list of Hospital Rules, the No Surprises Act (NoSA), and the Consolidated Associations Act. On January 1, 2023, all Good Faith Estimates (GFE) must include co-providers and co-facilities for all items and services included within the estimate. In preparation for that upcoming deadline, along with the launch of Turquoise Health’s free Instant GFE product, we’re taking a step back to see how it all fits together.

All these rules and acts came into existence relatively recently and in quick succession, and as a result, several phrases and acronyms have grown in popularity as providers and insurers work toward compliance. Over time, the trendy buzzwords and which rule or law they stem from have started to blur together. Turquoise gets asked a number of questions stemming from the perceived overlap of the various requirements and estimate tools. Valid yet persistent inquiries include:

  • Can our estimate tool create GFEs? Which rule or law does that put us in compliance with?
  • Are Advanced Explanations of Benefits required to be compliant with Transparency in Coverage (TiC) or NoSA? Or both?
  • What’s the difference between NoSA and TiC? Do any of these have to do with hospital or payer rate data?
  • Can Turquoise write a haiku to explain all this?

Getting Down to Brass Tacks

To begin, Turquoise asked our in-house Elle Woods to explain the difference between a rule and a law. After an important PSA directed at perm-wearers to resist anything that could deactivate their ammonium thioglycolate, we got to the good stuff:

A Rule typically springs from a law, and it’s usually written and published first for public comment as an Interim Rule and eventually as a Final Rule. Administrative agencies within the federal government put out rules and monitor compliance. The Hospital Rule and TiC both fit this category.

A Law comes from pieces of legislation that Congress (both the US House and US Senate) passes and the President signs. The Consolidated Association Act and NoSA fit this category.

Now that we’re all reading from the same sheet of music, let’s get into details on how the various acronyms and estimation tools fit within the broader price transparency landscape. Impress your friends at trivia night with the facts below…and after you’ve won, let us know what locale includes healthcare legislation as a trivia category. We want to send a team!

The following diagram provides a breakout of the differences in requirements:

*We’ll let you be the final say on if the haikus are actually helpful.

Other Relevant Acronyms


There are other acronyms floating around at conferences and in daily conversations that we’ve included in a non-exhaustive glossary below:

Acronym

Full-Text

Origin

Definition

QPA

Qualifying Payment Amount

NoSA

The median contracted rate for a qualifying item or service. The median contracted rate factors in contracted rates of all plans offered by the issuer in the same insurance market for the same or similar items or services provided in the same or similar specialty or facility of the same or similar facility type in the geographic region where the item or service is furnished.

IDR

Independent Dispute Resolution

NoSA

Federal dispute resolution process that occurs after the 30-day payment negotiation window between a provider and payer.

IDR Entity

Independent Dispute Resolution Entity

NoSA

Third party organization that has been certified and selected to review and resolve IDRs

PPDR

Patient-Provider Dispute Resolution

NoSA

Federal dispute resolution process for uninsured or self-pay patients if the final billed amount is at least $400 above the GFE

SDR Entity

Selected Dispute Resolution Entity

NoSA

Entities selected to review and resolve PPDRs

HIOS ID

Health Insurance Oversight System Identifier

TiC

Number that uniquely identifies each new qualified health plan approved by CMS. Required field within each payer’s machine-readable file.

PBE

Patients, Beneficiaries, and Enrollees

TiC

Defined list of eligible recipients of a cost-sharing estimate

Tying it All Together

As Turquoise CEO Chris Severn says, “Three birds. One SaaS Platform.” The Turquoise Compliance+ suite of products is getting developed with patient estimate tools, GFEs, and AEOBs all in mind. We are focusing on ways to maximize publicly-available data to power providers and payers’ creation of accurate and succinct cost-sharing estimates for patients.

Interested in other specific components of healthcare rules and laws or learning more about our Compliance+ products? Our door is open at info@turquoise.health