By Aaron Morein
Surprise! In 2020, congress passed the No Surprises Act, which protects patients from unexpected medical bills. Those rules which have been finalized were implemented January 1st, 2022. Providers will need to stay abreast of new rules and modifications coming out later this year.
Why was the No Surprises Act Passed?
Patients often have trouble understanding their insurance benefits or knowing how much care will cost. In addition, out-of-network providers can operate within in-network facilities. Thus, patients can reasonably use out-of-network services inadvertently and receive a surprise “balance bill”: charges to cover the difference between an out-of-network provider’s billed charge and the amount the health plan paid. Prior to No Surprises, only select states and Medicare and Medicaid had protections for patients against surprise medical bills.
No Surprises Act Summary
No Surprises expands restrictions on out-of-network charges for patients with health insurance. If a health plan holder
- receives emergency services from an out-of-network provider,
- receives nonemergency services provided by out-of-network providers at in-network facilities, or
- requires air ambulance emergency services,
The health plan provider cannot charge more than that service’s median in-network rate.
It further stipulates that patients are entitled to a good-faith estimate of cost of care up front for most healthcare services. Healthcare facilities must provide an easy-to-understand notice of these new protections and a contact whom they may reach out to if they feel these protections have been violated.
Additionally, this bill provides dispute-resolution opportunities for
- Payment disputes between insurers and healthcare providers
- Uninsured and self-pay individuals who receive a medical bill substantially higher than the good faith estimate they get from the provider.
- For services provided in 2022, patients may file a dispute claim within 120 days of the date of a bill that is at least $400 greater than the good faith estimate.
How Providers Can Comply
The basic steps you need to take are given here. For more complete descriptions, please access the links below.
Display a notice of surprise billing protections on your website and in your office. The easiest way to do this is to edit the model notice offered by HHS.
In some circumstances, providers must also display information about the right to receive a good faith estimate. CMS has these requirements posted here
Ask patients if they have insurance and if they intend to submit claims or to opt-out of their benefits. If they do not have in-network benefits or want to opt-out of them, inform them of their right to a good faith estimate and dispute resolution.
Supply an estimate of the cost of care before providing services. Timeframe requirements are as follows:
- No later than one business day if the appointment is scheduled more than three days in advance
- No later than three business days if the appointment is scheduled more than ten days in advance or an estimate is requested without scheduling an appointment.
A good faith estimate may include services for up to 12 months, including an estimated number of services needed during that period.
Detailed information for good faith estimate requirements are available on the APA services website.
Other new requirements are detailed by the CMS here
New rules are continuing to be updated, so check for announcements here.