Response to 60-day Comment

60-day Notice Comments & Response Summary
Patient Provider Dispute Resolution Requirements Related to Surprise Billing; Part II
(CMS-10853/OMB control number: 0938-NEW)
HHS received one comment from American Association of Oral and Maxillofacial Surgeons
(AAOMS) related to an information collection request (ICR) HHS released concerning CMS10853, a Paperwork Reduction Act (PRA) document detailing requirements to the patient
provider dispute resolution requirements related to surprise billing. This is the reconciliation of
the comments and it addresses the following comments.

Comment #1:
AAOMS pointed out that, as currently implemented, the PPDR process requires a provider to
accept/receive a payment amount less than the charged amount for the unforeseen items and
services not included in the good faith estimate, even when such charges are substantiated by
credible information. The failure of the PPDR process to recognize the billed amount as the
appropriate payment amount, when warranted, unfairly penalizes providers for the treatment of
unforeseen medical circumstances.
Response:
We appreciate AAOMS’s response to our comment solicitation, but this comment would require
HHS to make changes to the regulations at 45 CFR 149.620 and is therefore out of scope for the
changes related to this PRA package. HHS will take it into consideration for potential future
rulemaking.

Comment #2:
AAOMS understands and appreciates the consumer protections established under the federal
surprise billing regulations but they generally disagree with HHS that the median payment rate as
defined is reflective of fair market pricing for healthcare items and services, nor that it reflects a
reasonable payment amount. They argued that that actual market value may vary based on
factors such as provider reputation, patient volume, service quality, geographic location, local
competition, negotiations between payers and providers, government regulations, fee schedules
and other factors that may not align with market forces.
Response:
We appreciate AAOMS’s response to our comment solicitation, but this comment would require
HHS to make changes to the regulations at 45 CFR 149.620 and is therefore out of scope for the
changes related to this PRA package. HHS will take it into consideration for potential future
rulemaking.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be
privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not
authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Comment #3:
In line with comment #2, AAOMS suggested HHS to consider updating the methodology for
payment determinations under the PPDR to align with the federal IDR process. Specifically, they
requested HHS to consider allowing the final payment amount for medically necessary services
due to unforeseen circumstances to be equal to that of the total billed charges, when warranted.
Response:
We appreciate AAOMS’s response to our comment solicitation, but this comment would require
HHS to make changes to the regulations at 45 CFR 149.620 and is therefore out of scope for the
changes related to this PRA package. HHS will take it into consideration for potential future
rulemaking.

Comment #4:
AAOMS indicated the credibility standard under the patient-provider dispute process is
ambiguous. As a result, they suggested HHS to consider issuing guidance to allow a
determination of the type of information that meets the credibility standard in relation to the
patient-provider dispute resolution process.
Response:
We appreciate AAOMS’s response to our comment solicitation, but this comment would require
HHS to make changes to the regulations at 45 CFR 149.620 and is therefore out of scope for the
changes related to this PRA package. HHS will take it into consideration for potential future
rulemaking.
Comment #5:
AAOMS believes that using a flat $400 rate for the dispute threshold does not recognize the
complex nature of many medical, dental and surgical items and services. Therefore, they
encourage HHS to reconsider what is defined as “substantially in excess” regarding the total
billed charges by a provider or facility in relation to the expected estimate of charges. For
example, they indicated HHS may consider utilizing the greater of either $400 over the expected
charges presented in the good faith estimate or a predetermined percentage of the total billed
charges as the threshold to trigger the patient-provider dispute resolution process.

Response:
We appreciate AAOMS’s response to our comment solicitation, but this comment would require
HHS to make changes to the regulations at 45 CFR 149.620 and is therefore out of scope for the
changes related to this PRA package. HHS will take it into consideration for potential future
rulemaking.
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be
privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not
authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.