In a recent article, we discussed the No Surprises Act (NSA) and how it will affect payer organizations (e.g., commercial health plan providers, Medicare, and Medicaid), particularly when it comes to managing member claims, processing payments, and communicating with members. But the No Surprises Act won’t just affect the way payer organizations operate—it will also have a significant impact on operations and billing for provider organizations as well.
In this article, we’ll take a closer look at the details of the No Surprises Act, outline the parts of the new law that are most relevant to provider organizations, and discuss what provider organizations can expect now that the No Surprises Act is in effect.
The No Surprises Act, explained
On July 1, 2021, an interim final rule was issued by the Department of Health & Human Services (HHS), the Department of Labor, the Treasury Department, and the Office of Personnel Management (OPM) implementing the act. The No Surprises Act was introduced in 2019, but it wasn’t until the end of 2020 that Congress settled on the specifics of the bill and included it in the year-end Consolidated Appropriations Act (CAA).
The No Surprises Act was created to protect patients from surprise medical bills, especially those resulting from gaps in coverage for emergency services. Surprise balance billing can occur in a variety of different ways, but the most common is when patients have an urgent or emergency medical situation. In these instances, there may not be a facility within a reasonable distance that’s in-network, which means they have to get care from an out-of-network facility. But if their policy does not cover out-of-network services, they are responsible for the cost of the care—which can quickly and easily total tens of thousands of dollars.
Surprise balance billing also occurs when patients go to an in-network facility, but the services are delivered by an out-of-network provider. Even in cases of elective procedures when the patient chooses an in-network facility and in-network provider beforehand, if the provider’s surgical team includes an out-of-network anesthesiologist or assistant surgeon, the patient is on the hook for that provider’s costs. Under the No Surprises Act, patients are no longer financially responsible for these unexpected out-of-network medical costs. Instead, group health plans and provider organizations will be required to work together to settle outstanding medical bills without involving the patient.
While the interim final rule was issued in July 2021, the key date to remember for the No Surprises Act is January 1, 2022, when most of the provisions in the act will formally take effect.
Key elements of NSA for providers
Many provisions in the No Surprises Act require payers and provider organizations to share the responsibilities, but there are some cases where the provider organization will need to take the lead to remain compliant with the new law. Here are some of the most significant provisions that providers need to be aware of.
Disclosure of Balance Billing Protections
Effective January 1, 2022, all healthcare providers are required to make information on patients’ rights regarding balance billing publicly available, both in their facilities and on their websites. This disclosure must include the requirements under the law, any state-level protections that may apply, and contact information for state and federal government agencies that patients can contact to report violations.
Section 104: Notice and Consent for Balance Billing by Out-of-Network Providers
Prior to the No Surprises Act, if a provider or facility delivered medical services to an out-of-network patient, the common practice was to send the patient a bill for the cost of whatever services the patient’s insurance would not cover. In many cases, this meant that patients who received a medical bill from the provider were often unaware of the total cost, the fact that their insurance did not cover the full cost, or even the fact that the provider was out-of-network in the first place. Consider that for patients still grappling with their need for emergency or scheduled services, the surprise bills create anxiety and often financial hardship for excessive payment amounts.
Under the new law, out-of-network providers must provide written notice of the costs within 72 hours of the item or service being delivered and obtain consent from the patient. At a minimum, the written notice must contain:
- Notification that the provider is out-of-network
- A good faith estimate of the charges that will be incurred for the item or service
- A list of in-network providers at the facility (if the facility is in-network)
- Information on prior authorization or other care-management requirements
- A clear statement that consent is optional and that the patient can choose an in-network provider instead if they wish
The notice also must be made available in the 15 most common languages spoken in the provider’s area. For out-of-network healthcare providers delivering services at an in-network facility for the patient, the organization—not the provider—is responsible for maintaining these consent documents, and records of notice and consent must be retained for seven years after the date of service.
When does notice and consent not apply?
In some instances, the notice and consent process does not apply, primarily when the patient cannot reasonably be expected to choose another provider or facility. The key items and services that are exempt from the notice and consent process are:
- Emergency medicine
- Diagnostic services
Even in cases where an out-of-network healthcare provider has delivered notice and received the patient’s consent to balance billing for a procedure, if an urgent medical need arises during the procedure, any additional services or items needed to address that need are not covered by the notice and consent process. In addition, out-of-network providers can only use the notice and consent process if there is an in-network provider at the facility.
Section 105: No Surprise Air Ambulance Services Bills
Under the No Surprises Act, air ambulance services—medical transport using a helicopter or airplane—cannot balance bill patients for their services. Patients are only required to pay the in-network cost-sharing amount that would normally apply. In addition, out-of-network air ambulance providers are barred from sending patients balance bills for any amount above and beyond their in-network cost-sharing amount.
Section 112: Patient-Provider Dispute Resolution
Healthcare providers and provider organizations are required to share “good faith estimates” of the total expected charges with the patient’s health insurer or, if the patient is uninsured, the patient themselves. The No Surprises Act also establishes a patient-provider payment dispute resolution process for uninsured patients whose final bill is substantially higher than the good faith estimate they received beforehand. Such independent dispute resolution aims to promote voluntary negotiations.
How provider organizations should adjust to the No Surprises Act
To remain compliant with the new rules under the No Surprises Act, provider organizations will need to make some adjustments. Some of the most important ones follow.
Billing departments within provider organizations are used to billing the patient first and letting the patient hash out the details with their insurer. On January 1, 2022, however, that will no longer be the case, and provider organizations need to adjust their billing processes so that the health plan, not the patient, is the first point of contact for an outstanding balance.
New payer relationships
Before the No Surprises Act, provider organizations only had to have relationships with the payer organizations with whom they contracted. There was no need to establish working relationships or processes with any payer for whom the provider was out-of-network. In other words, the provider’s bill was a matter for the patient and their insurer to handle.
Starting on January 1, that will change. Because patients are largely being removed from the medical billing process, provider organizations must create relationships with a variety of new payer organizations. In addition, because each health plan has its own compliance and claims submission processes, provider organizations will need to quickly get up to speed on these processes to ensure they get paid for services as quickly as possible.
Adapting to new rates
Providers may also need to adjust their billing and rate expectations when working with new payers. The No Surprises Act has not yet set minimum payment rates for services and items, so provider organizations and health plans will need to work together to establish rates that are acceptable to both parties. By establishing these rates proactively, healthcare providers can avoid a potentially lengthy provider-payer dispute resolution process down the road.
Adjusting to state-federal government overlap
In 28 states, there is already some form of surprise billing protection, but these protections vary depending on the state. As a result, some states may cover elements of surprise billing that the No Surprises Act doesn’t cover (and vice versa), which could mean that some parts of a balance bill will be governed by state law while others are governed by federal law. It’s a potentially thorny area for provider organizations, and so far there hasn’t been much guidance from HHS on how to navigate the areas of overlap.
The changes in the No Surprises Act will affect different parts of a provider organization, and ensuring the organization is prepared to seamlessly adjust to the new law will be vital in the months to come. Technology solutions like provider data software can help organizations effectively navigate these changes. To learn how symplr can help your organization adjust to this new landscape, request a demo today.
More NSA resources from symplr
- Blog: What Does the No Surprises Act Mean for Payer Organizations?
- Webinar: Ask Our Attorneys: How Payers and Providers Prep for the No Surprises Act