CMS guidance: health plans cannot force physicians to incur fees for receiving electronic payments 

The Centers for Medicare & Medicaid Services (CMS) released new guidance last week in response to concerns raised by the American Academy of Family Physicians and other groups about health plans and their vendors charging fees for electronic payments to physicians.

The guidance states that HIPAA electronic funds transfer (EFT) and electronic remittance advice (ERA) standards permit health plans to pay claims by virtual credit card (VCC), which may include fees that aren’t subject to Health and Human Services’ regulations.

However, the guidance also affirms that health plans cannot force physicians to receive claims payment by VCC and accept the associated fees. If physicians or other health care providers request electronic claims payment via other (fee-free) means, the plan must comply. The guidance also says health plans may not require physicians to deal with a specific vendor in order to receive electronic payments:

Nothing prevents a business associate that operates on behalf of a health plan in conducting Stage 1 payment initiation transmissions from offering services to a provider related to Stage 3 transmissions or other payment/and or reassociation processes. However, a health plan may not require a provider to accept those services, and parties should be cognizant that any health plan attempt to require a provider to agree to receive unwanted payment or reassociation services from a specific vendor designated by a health plan as a condition of receiving EFT and ERA using the adopted standards may be construed as the health plan adversely affecting the transaction or the provider on the basis that the transaction is a standard transaction.

Therefore, while the CMS guidance does not specifically address the appropriateness of fees levied by some health plan vendors, it does show that practices may be able to avoid interacting with vendors that charge fees. The agency advises physicians to be aware of any agreements they have with health plans related to claims payment terms.

If you believe a health plan has failed to comply with any of the adopted standards or operating rules, you may file a complaint with CMS through the Administrative Simplification Enforcement Testing Tool. Questions about this latest guidance or other topics related to EFT or ERA standards and operating rules should be sent to AdministrativeSimplification@cms.hhs.gov with the subject line: EFT ERA Guidance Question. For more information, please visit the CMS Administrative Simplification website.

— Kent Moore, senior strategist for physician payment, American Academy of Family Physicians

Posted on March 31, 2022, by Kent Moore