With the introduction of the No Surprises Act in January 2022, patients can rest assured that they will have full transparency into their medical expenses. Surprise medical expenses can occur when a patient inadvertently receives medical care from an out-of-network provider. If there is a dispute over charges, providers must work with the health insurance company in an independent dispute resolution process. Unfortunately, this win for patients has created new challenges for providers and healthcare facilities.
What should providers know about the No Surprises Act?
The No Surprises Act provides patient protections against surprise billing in three specific areas:
- Emergency services. The No Surprises Act covers most emergency services provided in hospital emergency rooms, freestanding emergency departments, and even air ambulances.
- Postemergency stabilization services. This applies to treatment or services rendered after a patient has reached a stable condition following emergency care.
- Nonemergency services. The No Surprises Act covers nonemergency services from an out-of-network provider within an in-network hospital or facility.
In addition, the No Surprises Act outlines a notice and consent process requiring out-of-network providers to notify a patient about their network status and obtain the patient’s written consent to receive treatment at least 72 hours before providing that treatment. This process allows patients to choose an out-of-network provider, despite the added expense, when there is substantive reason to choose that provider.
The No Surprises Act also states that in instances where balance billing is prohibited, cost sharing for insured patients is limited to in-network levels or amounts. Furthermore, providers must give a good faith estimate of treatment charges to self-pay or uninsured patients, and if the billed amount is more than $400 above the estimate, the patient can dispute the bill. Provider organizations and payers must ensure continuity of care when a provider’s network status changes, and providers and payers must take certain steps to improve the accuracy of provider directory information.
How can providers remain compliant?
Due to the number and complexity of changes required by the No Surprises Act, the oversight and penalties were lenient during 2022, as providers learned to navigate the new rules. But that will likely change going forward. Here are some tips to keep your health facility compliant:
- Establish an implementation team with key representatives from legal, compliance, billing and finance, payers, operations, and IT.
- Plan for the financial implications of implementing changes necessitated by the No Surprises Act.
- Create processes to identify services subject to the surprise billing protections.
- Create and update policies and procedures relevant to No Surprises Act implementation.
- Provide training for administrative, frontline, and billing staff.
- Document written agreements with facilities, and ensure patients are provided the disclosures.
- Ensure the notice and consent process is satisfied before balancing bills.
- Establish strategies for solving payment disputes.
- Establish a decision-making process to help providers decide when it’s financially prudent to accept a patient’s initial payment to avoid the costly open negotiation period.
The No Surprises Act is not static — it will grow and change. And there currently are legal changes that could affect its implementation. That’s why it’s important to stay compliant with current provisions but also keep up with new developments and remain agile enough to maintain compliance. By partnering with a revenue cycle management team, like TruBridge, providers can focus on patient care while ensuring their compliance with the law’s provisions. To learn more, visit TruBridge.com.
