The No Surprises Act is about to dramatically change how your practice gets paid for out-of-network services.
The Department of Health and Human Services (HHS) is not kidding around when it comes to the enforcement of the No Surprises Act. If you fail to comply, you can be hit with fines of up to $10,000 per violation. Luckily, you have until 2022 to get ready. So, what exactly is in this new law and what can you do right now to ensure your compliance by the go live date?
Transparency in Billing No Surprises Act.
The overall purpose of the Act is to protect patients from receiving surprise medical bills in both emergency and nonemergency situations. In a nutshell, the No Surprises Act makes balanced billing illegal.
Balanced billing is when you charge an out-of-network patient for the portion of your bill that wasn’t covered by their insurance. The No Surprises Act prohibits you from billing a patient at a higher rate than an in-network provider. So, if you treat an out-of-network patient, they are only financially responsible for what they would have paid to an in-network provider. So, you can’t hold them liable for higher amounts unless you provide written notice and consent 72 hours in advance of the appointment and the patient consents to pay the higher amount.
Note: In emergency situations, the No Surprises Act applies to out-of-network air ambulances, but not ground ambulances.
Advanced Explanation of Benefits
The Act also aims to increase transparency so that your out-of-network patients better understand what they are responsible to pay. The goal is to stop patients from being responsible for an invoice they never expected to receive.
To help achieve this, your patients can request to receive an Advanced Explanation of Benefits (AEOB) from their health plan before a medical service is delivered. This statement must provide the following information:
- In network: The rate of payment for your services
- Out-of-network:
- Direct your patient to an in-network physician at the same facility (if possible)
- Contact your practice for a good faith estimate for the services in question, and then present it to the patient.
- Clearly outline to the patient what their insurance will pay for the out-of-network services.
- Provide a good faith estimate to the patient of what the plan will pay based on your estimate and the amount applied to the patient’s out-of-pocket maximum and deductible
- Spell out any disclaimer that coverage is subject to medical management requirements, if applicable
- Clearly communicate that the prices provided are only an estimate and are subject to change.
Importantly, if your out-of-network patients receive faulty information from their insurance plan about your practice, the services you provide and/or the cost, they are not responsible to pay. For example, if you are listed as in-network, but really aren’t, the patient is only on the hook for the in-network cost associated with the service.
To comply with the No Surprises Act, insurers will also have to pony up price comparison information by phone, develop a web-based price comparison tool, and maintain up-to-date provider directories.
Payment Dispute Process Change
Another component of the No Surprises Act is that it also mandates arbitration to settle payment disputes between you and payors. This arbitration process is a huge change. If you and a payor can’t come to agreement on a payment after 30 days, you are required to go to arbitration.
You and the payor are required to each make an offer to the arbitrator to resolve the dispute. The arbitrator chooses one of the offers as final and binding, taking into account the average in-network rate for the service, level of care given and a variety of other factors.
It’s also important to know that the losing side pays for the arbitration. So, if your office is not chosen, not only will you be out the money you expected to receive, but you’re also required to pay the fees associated with the dispute. Start Preparing Now
Here are three processes you can be working on now to ensure your compliance with the upcoming No Surprises Act rules:
- Patient communication. You must ensure your patients understand their financial responsibility up front. This will help you meet the bill’s requirement that you have patients’ consent to receive out-of-network services for more than the in-network cost. Importantly, if your relationship with your patient’s insurer changes, you must quickly and clearly relate that to them so they know what is changing and what they can expect.
- Collection policy. Your policy must be clearly written and well understood by your entire staff. They are the ones who will be handling patient questions for the most part, so they must be able to convey the processes that you have documented regarding payment. You’ll also need to train your staff on any new collection processes.
- Out-of-network Mitigation strategy. Your practice should look for ways to avoid balanced billing situations. If you do decide to take on out-of-network patients, you have 72 hours to gain their consent before the service is delivered. One simple tactic is to implement a calendar. Be sure to check in with patients PRIOR TO that 72-hour deadline to ensure they know what the service is and the fee they’re expected to pay at the time of their visit.
There’s a lot to learn about the new No Surprises Act rules, but you don’t have to go it alone. On Wednesday, April 21st at 1pm ET, practice management expert, Owen Dahl, MBA, LFACHE, CHBC, LSSMBB, will present an online training on how the No Surprises Act will affect your out-of-network collections. You’ll walk away from this training with a step-by-step actionable strategy to safeguard your practice, pinpoint weaknesses and stay out of arbitration.
Sources:
AMA High-Level Summary of the No Surprises Act (ama-assn.org)
Unpacking The No Surprises Act: An Opportunity To Protect Millions | Health Affairs
Key Ways Providers Can Prepare for New Surprise Billing Rules (revcycleintelligence.com)
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