If your practice has been lax about adopting the No Surprises Act requirements, you could be setting yourself up for significant audits and fines (of up to $10,000 per violation). And just as importantly, you may be shorting yourself of deserved reimbursement if you fail to notify patients up-front what their out-of-network costs will be.
As you are probably aware, the No Surprises Act requires you to notify patients before providing out-of-network services so they know exactly what their out-of-pocket costs will be. In other words, you’re making sure your patients experience no surprises in terms of what they’ll owe for medical services. Many medical practices continue to find complying with the No Surprises Act “very daunting,” and some are still working to figure out how to fully incorporate the process.
To get a handle on how the No Surprises Act should be prompting changes at your practice, check out these key points.
Patient Disclosure Document Requirements
The No Surprises Act requires that your practice have a document available for patients who are enrolled in commercial health plans that tells them what their rights are when it comes to balance billing. This document should explain which of the services that your practice provides are in-network, and what they’ll be expected to pay.
You should let your patients know at least 72 hours prior to administering an out-of-network service, so they are able to determine if they want to get the service or not. But that’s not the only document you’ll need to have at the ready. You’ll also have to create a template for giving patients the estimates you’ll be making in the future.
Good Faith Estimate Complexities
To remain in compliance with the No Surprises Act, your practice must also provide a Good Faith Estimate to all of your self-pay patients. In addition to this, if your patients with insurance request an estimate, you are required to provide one for them too.
When preparing your Good Faith Estimate, it’s important to cover every possible expense the patient may be charged, from the encounter and procedure to supplies, tests, and more. In essence, you’re letting patients know what their out-of-pocket costs will be from start to finish. And although you are providing an estimate, it is crucial that you are as accurate as possible. If not, and you charge over $400 more than what you estimated, your patient can dispute the amount due. If this happens, your practice will have to fight to receive even partial payment or end up receiving no reimbursement at all.
Note: For more specifics on how to implement a compliant Good Faith Estimate, check out this recent blog post, No Surprise Billing Act: Ace Good Faith Estimates for Self-Pay.
Dealing with No Surprises Act Disputes
CMS has made it easy for patients to dispute your invoices under the No Surprises Act. However, they must do so within 120 days of the billing date, and they don’t need a lawyer to do so.
To dispute an invoiced charge, patients simply need to contact your practice and let you know that they will not pay for the service because it wasn’t on your estimate. In addition, CMS has directed the states to include No Surprises Act reviews as part of their regulatory process, meaning auditors could be checking to ensure that your practice is complying with the law.
The American Medical Association filed suit against the government for moving the No Surprises Act forward too quickly, without enough information about how to protect medical practices from illegitimate patient complaints. “Congress established important patient protections against unanticipated medical bills in the No Surprises Act, and physicians were a critical part of the legislative solution,” said AMA President Gerald E. Harmon, M.D. in a statement. “But if regulators don’t follow the letter of the law, patient access to care could be jeopardized as ongoing health plan manipulation creates an unsustainable situation for physicians.”
This is why it’s essential to correctly calculate your good faith estimates and give them to patients in every applicable case. To download a free customizable Good Faith Estimate template, visit this link.
There’s much more to know about how to ensure your compliance with the No Surprises Act. To get expert advice on overall No Surprises Act compliance, including how to accurately provide Good Faith Estimates, check out this multi-session online training, 3-Part Series: Master No Surprises Act 2022 Changes, Avoid Hefty Fines, provided by expert lawyers Daphne Kackloudis, Esq., Ashley Watson, Esq., Gina L. Campanella, Esq., FACHE, and David Vaughn, JD, CPC. This training breaks down the complexities of complying with the No Surprises Act and provides you with actionable steps you can put into place right away.
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