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No Surprises Act Articles

A Comprehensive Friendly Guide on No Surprises Act January 31, 2022

No Surprises Act

How well do you know the No Surprises Act? What are the implications of the Act for healthcare providers? If these questions are on your mind, we can provide a comprehensive and friendly guide on the No Surprises Act (NSA). 

What Is the “No Surprises Act”?

The No Surprises Act (NSA) took effect on January 1, 2022. It was signed into law as part of the Consolidated Appropriations Act 

COVID-19, on December 27, 2020. Moreover, the Act prevents healthcare consumers from being surprised by medical bills and shields them from insurance disputes. The Center for Medicare and Medicaid Services (CMS) has created a site for future updates on No Surprises Act implementation documents.

What Is a Surprise Medical Bill?

A “surprise medical bill” refers to unexpected higher charges after receiving care from an out-of-network provider. The out-of-network provider or facility may also bill you for the difference between the billed charge and what your health plan pays unless prohibited by state law. Balance billing also describes this situation. Surprise medical bills can also refer to unanticipated balance bills from out-of-network providers.

Furthermore, these protections are already available to those with Medicare or Medicaid.

Understand the “No Surprises Act” in Terms of Its Applicability

The No Surprises Act applies to all states without a law that prohibits balance billing. Whenever there is an existing law, it will take precedence over the Act. State or federal laws may apply to providers with a multi-state practice regarding insurance reimbursement. Billing companies and providers can benefit from this knowledge in dealing with reimbursements and perceived underpayments.

Surprise bills from healthcare providers must not exceed more than the in-network costs.

Providers cannot charge the patient more than the in-network cost-sharing amount covered by NSA, or a penalty of up to $10,000 may apply.

Nowadays, out-of-network doctors and hospitals are billing their patients directly for their total, undiscounted fees. Thus, the patient needs to submit a claim out-of-network to their insurance company and collect any reimbursement. The process starts this year. First, providers must verify the patient’s insurance status before submitting the surprise out-of-network bill. Providers are also “encouraged” to include information about NSA protections on the claim itself (e.g., whether the patient has waived his balance billing privileges).

On the other hand, the health plan must notify the provider of the applicable in-network cost-sharing amount within 30 days. Cost-sharing generally depends on the plan’s in-network rate and its pay for the service. Consumers will receive a notice that the health plan has processed the claim, along with the amount of in-network cost-sharing they owe to the out-of-network provider. Until then, the out-of-network provider may bill the patient no more than the in-network cost-sharing amount.

How the Act Impacts Physicians

The No Surprise Act prevents providers from surprisingly billing customers. Out-of-network providers must charge the in-network fee from their patient’s health plan.

If physicians are part of a smaller practice and do not have the resources to use the IDR process to ensure fair compensation, the No Surprise Bill law might pose financial difficulties. Physicians may face more financial stress, including the COVID-19 pandemic. 

No Surprises Act: Does It Apply to Clinics?

Some of its rules do. However, many sources claim clinics are exempt from these rules. 

First, it is helpful to think of the Act as having three prongs. The first prong deals with emergency services.

Secondly, it deals with patients undergoing treatment at a hospital or ASC.

The last prong considers estimates for patients who are not using insurance to cover their care. This is either because they are uninsured or refuse to use their insurance.

The third prong refers to clinics; you must provide estimates to patients without insurance. If physicians offer services in a hospital or an ASC, the first two prongs will apply. 

What Is the Good Faith Estimate (GFE)?

From January 1, 2022, patients without insurance can get a good faith estimate (GFE) for any service scheduled within three business days in advance. All practices and facilities must comply with this rule. In addition, GFEs must include details such as diagnosis and procedure codes, as well as your NPI.

The three-day notice applies to every scheduled service, including office visits. If you plan the event between three and nine days ahead, you are required to submit the estimate within one business day after you schedule it. You get three business days to provide the estimate if the event is more than ten days away.

What’s Not Covered by the No Surprises Act?

There is no prohibition against surprise out-of-network billing under the No Surprises Act. However, there are two critical exceptions:

  • Ambulances: The Act covers air ambulances but not regular ground ambulances.
  • Facilities: Hospitals, emergency rooms, and outpatient surgery centers are covered by the Act. There are also plans to include clinics and urgent care centers in the future.

Medicare, Medicaid, TRICARE, Veterans Affairs Health Care, and Indian Health Services are not covered under these provisions since they are already protected against surprise medical bills.

Are There Other Resources Available? 

HHS has released an FAQ on its website: https://www.cms.gov/CCIIO/Resources/Regulationsand-Guidance/Downloads/Guidance-Good-Faith-Estimates-FAQ.pdf  

No Surprises Act Summary

Some of the notable provisions of the Act include:

  • It goes into effect on January 1, 2022, and abolishes balance billing, except in particular circumstances.
  • Balance billing laws apply to Employee Retirement Income Security Act (ERISA) plans and state-regulated plans in states without balance billing laws already in place.
  • Patient deductibles for out-of-network emergency care are the same as for in-network care, and deductibles must be printed on insurance cards.
  • Pay the provider directly or respond with a complete denial within 30 calendar days of receiving the claim.
  • Establishes an Income-driven Repayment (IDR) process for dealing with out-of-network payment disputes.

Throughout 2021, insurers will have to report to state-level all-payer claims databases. Also, rules for qualifying payments (defined as the median of contracted rates as of January 31, 2019, adjusted for inflation from 2019-2021) and the IDR process. 

Because many key provisions of the new law are still unclear, how should a practice prepare for such changes? 

  1. Be familiar with the law in the state(s) in which the practice is located.
  2. Establish a method that identifies current out-of-network payment trends. Next, compare them with payments received after January 1, 2022. 
  3. Prepare to file underpaid claims in the IDR process.

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