Set to take effect on January 1, 2022, the No Surprises Act aims to protect patients against surprise medical bills. After years of debate, the Act was passed at the end of 2020. What is this Act and what does it entail? We will provide a brief summary here to help you understand a bit better.

There are two parts to this, we must first understand what surprise medical bills are.

Surprise Medical Billing

Surprise medical bills are those receive unexpectedly by patients after being treated by an out-of-network provider.

These surprise bills occur in both emergency and non-emergency situations. For example, when a patient visits an emergency room at an in-network facility, the physician may be a non-contracted, or an out-of-network provider. Likewise, in non-emergency situations, when a patient has to consult multiple specialists, not all may be in-network. People typically choose in-network providers, but they do not always choose every member of their healthcare team, i.e. anesthesiologists, radiologists, etc.

Due to the fact that they are actually out-of-network providers, the patients usually have to pay more for the visit.

What is the No Surprises Act?

The ultimate goal of the No Surprises Act is to protect patients against these surprise bills. Some states, such as Texas, put laws into place back in January 2020, but for the rest, these new regulations will affect healthcare providers and insurance providers. We’ll focus on healthcare providers in this post.

Some key components of the new Act:

Costs for emergency and non-emergency services

  • For emergency services, out-of-network providers, at both in-network and out-of-network facilities, cannot bill patients more than the cost-sharing amount of in-network providers at in-network facilities.
  • For non-emergency services, out-of-network providers at in-network facilities cannot bill patients more than the cost-sharing amount of in-network providers, unless notice and consent requirements are met.

Audit process for median contracted rates

  • Sponsors and insurance providers will be audited to ensure they are compliant and not charging more than the median in-network rate.

Negotiations:

  • Any negotiations on reimbursements will be between healthcare providers and insurance plan providers, not involving any patients.

Notice and Consent:

  • When possible, patients must be notified no less than 72 hours before the service is delivered of the following:
    • their out-of-network status
    • estimated amount that they may be charged
    • list of participating providers at a non-participating facility that the patient might be referred to.
  • Out-of-network providers who obtains notice and consent must keep the documents at least a 2 year period.

Provider Directory Information

This refers to a list of providers and facilities who have a contractual relationship with an insurance issuer

  • No later than 1 year after January 1, 2022, healthcare providers and facilities will need a process in place in which the provider shares provider directory information with their contracted health insurance issuers.
  • Providers must share information when:
    • The provider or facility enters into a contract with the insurance issuer
    • The provider or facility terminates a contract with the insurance issuer
    • There is significant, relevant change to the information in the directory
    • Determined appropriate by the provider, facility, or Secretary

Enforcement:

  • Enforced by each state
  • A process to take in complaints about violations of this Act
  • Possible civil monetary penalties if a provider or facility is in violation. Maximum fine of $10, 000.
  • Penalties may be waived if a healthcare provider unknowingly violated the act. The provider must within 30 days withdraw the bill that violated the Act and provide reimbursements equal to the difference between the bill and the allowed amount plus an interest rate determined by the Secretary in charge.

For more information, the compete Act is outlined on the Congress website.

As preparations begin, states like Ohio have started looking into how to implement these new regulations and have expressed the need for feedback on how to design protections.

 

How is your facility preparing for the new No Surprises Act? At Americare Network, we will continue to support your practice in medical billing. Our focus allows us to organize and speed up the process, collection payments faster than in-house billing. Our expert team will know what to bill and the accurate amount to bill. Give us a call today at 801-719-1171 or book a free consultation to learn more about how we can help your practice add revenue in today’s environment.