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.
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 expands restrictions on out-of-network charges for patients with health insurance. If a health plan holder
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
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:
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.