Let’s go over the 2022 new “No Surprise Act” created to protect patients covered under group and individual healthcare plans from receiving surprise medical bills.
Okay so let’s break it down. There are a lot of details in this so hang in there with me. As always, these are recommendations only, please consult with your billing department, legal team, or insurance carriers directly.
We have all been there, right? Shocked by a bill from an out-of-network provider when you received services from an in-network facility where services were provided. This is just one example of what the No Surprises Act is trying to prevent. And it is also extremely frustrating for the physicians and providers in our hospitals and facilities who haven’t had much control over that process. On the physician side, I still expect
I will clarify that some states already have state laws pertaining to surprise bills and disputes. Therefore this will not replace those but instead create a “floor” of protection against surprise bills. Meaning if the state has a surprise billing law that provides at least the same level of protection or greater than the current state law will apply. This also extends to the protection regarding having a concrete dispute process which I will outline later.
Provides protection for really two groups of people:
- If you have private health insurance and get surprise bills when you are receiving certain types of services
- If you are uninsured or decide not to use your health insurance and self-pay then you can get a good faith estimate of the cost of your care upfront before your visit. Then if your charges are much greater than that, dispute the charges
Services Covered under No Surprise Act
- Emergency services
- Non-emergency services from out-of-network providers
- Services from an out-of-network ambulance service provider
The bill also establishes independent dispute resolution processes for several scenarios:
- Payment disputes between plans and providers
- Uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate that they get from the provider
The contact for the dispute process must be outlined on the bill as well as a description of the protections and how to report any violations. It is expected that providers/facilities post this information prominently at the location and on a public website if applicable
What was the issue with surprise bills?
Did you know that prior to this act; 1/5 ER visits resulted in a surprise bill and 1/10 facility bills after surgery resulted in a surprise bill.
The biggest complaint from patients prior to the No Surprises act was the visit to a facility for care that was in-network but had care from providers that were out-of-network and therefore received out-of-network bills even though you arrived at the facility that was in-network. As I mentioned, I am sure many of us have seen this too! And not only would those bills be higher but you could and would be balance billed for those out-of-network charges. The same could be said regarding an in-network provider and out-of-network facility though that seems to be less common.
Details on the coverage?
- Ban surprise bills for emergency services
- Even if you get them out of network and without prior authorization
- Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) and balance bills for most emergency and some non-emergency services.
- You can’t be charged more than in-network cost-sharing for these services.
- There are some exceptions to this, specifically, if the attending physician states that the patient is stable and therefore could be transferred to a participating provider/facility within a reasonable travel distance and is in a stable condition where they can receive written notice and provide informed consent regarding the additional costs
- We all know the likelihood of that happening
- Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
- This is a big one and I personally have had to happen during a minor surgical procedure for my family where the anesthesiologist was out of network but the facility where the procedure was done was in-network.
- Costs must be calculated by that out-of-network provider as if the provider were in-network essentially
- This really impacts ancillary services like ER, anesthesia, pathology, radiology, and neonatology even
- Ban balance billing for air ambulance services provided by nonparticipating air ambulance providers
- Provide good faith estimate in advance of scheduled services or upon request
- This is really for those uninsured or self-pay patients
- This will include in the written notice the expected charges, service, and diagnostic codes of scheduled services
- Also includes items or services that may be provided by other providers if those services are provided by the facility (i.e. anesthesia at the surgery center)
- Ensure continuity of care when providers network status changes
- This really applies when a provider or facility ends a contractual relationship with a plan and should continue supporting the care of the patient for up to 90 days after which the patient can be notified of the change in the providers network status
- There are even requirements around providers submitting directory information to the plans so that the directories are up to date and accurate
- This requires a notice when you leave the plan as well
- Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).
If a patient does not have health insurance or chooses to pay for care on their own without using health insurance and instead self-pay, then they should get a good faith estimate prior to services.
Patients with Medicare, Medicaid, Indian Health Services, and Veteran Affairs Health Care or Tricare already have protections and therefore these requirements do not apply.
If you are looking for help implementing appropriate billing practices or other operational solutions please do not hesitate to contact us.
References
https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf
Thank you for reading our blog! If you’re needing help going through all the complexities of billing regulations, come work with us! Go to NatinoalRevenueConsulting.com/contactus to sign up for an introductory Call. As a physician, I get what you experiencing and we look forward to supporting other practices.
