January 31, 2022

Category: Healthcare Industry, Healthcare Technology

IN A NUTSHELL:

  • No Surprises Act aims to prevent surprise medical bills
  • Applies to emergency and non-emergency healthcare
  • Critics say the Act may limit patient care access

The No Surprises Act is federal legislation which took effect at the beginning of this year and aims to benefit patients, yet has deeper consequences which affect healthcare providers and medical facilities.

The legislation is intended to protect patients from unanticipated medical expenses after receiving care from an out-of-network healthcare professional, hospital, or other medical facility. The situation can happen in emergency and non-emergency situations.

In a non-emergency situation, a patient may seek care at a hospital or freestanding emergency room which is in-network with their insurance plan. However, if the particular healthcare professional who provides care is not covered by the insurance plan, the patient would be faced with a large bill prior to the No Surprises Act. It often happens with emergency room doctors, anesthesiologists, physicians contracted by the facility, or those who serve on-call.

Before now, the health plan would pay only a portion of the bill and the patient would be responsible for the balance. On the surface the legislation seems like a win-win for patients, yet there are several moving pieces to consider.

Surprise billing in healthcare is a controversy which the No Surprises Act establishes federal protections against. Over the years various states have enacted their own legislation banning surprise billing, also known as “balance billing.”

However, there is also bi-partisan pushback against the No Surprises Act.

Lawmakers on both sides of the aisle claim the legislation favors insurance companies and could lead to payers setting unreasonably low payment rates. This would have a detrimental impact on patients’ access to care. If providers and facilities are unable to resolve a payment dispute with the payer, the number of health plans providers are enrolled in would narrow and small practices could be forced to close.

What Healthcare Providers & Facilities Need to Know:

In a nutshell, the No Surprises Act removes the patient from any conversations with medical billing companies or healthcare facilities regarding payment disputes when the patient’s insurance network declines reimbursement. In the event of a medical emergency, patients often have no say in which hospital they are transported to and whether or not they receive care from a healthcare provider in their insurance network. On the bright side, this new legislation removes the need for facilities to hire debt collection agencies as patients can no longer be hit with a large bill for a service they expected to be covered under their insurance.

Non-Emergency Situations and the No Surprises Act:

Of importance, protections under the No Surprises Act extend beyond emergency situations. It also includes post-stabilization services provided in a hospital following an emergency visit. Post-stabilization care is considered emergency care until a physician determines the patient can travel safely to another in-network facility using non-medical transport.

The No Surprises Act also requires that patients receive written notice and provide written consent to be transferred to a new facility.

Physicians are also required to make a disclosure regarding the patient protections against balance billing publicly available. The Department of Health and Human Services created a model notice (.pdf) that healthcare providers and medical facility administrators can use.

Other non-emergency situations covered under the No Surprises Act include when a patient chooses an in-network medical facility or an in-network healthcare provider, but is unaware that an additional healthcare provider involved in the course of their treatment, such as an anesthesiologist or radiologist, is an out-of-network provider.

This situation can also arise if a patient receives care from an in-network ambulatory surgical center, where specific providers may be out-of-network. Under the No Surprises Act, the maximum cost the healthcare providers may bill a patient is the plan’s in-network cost-sharing amount. Cost sharing is what a patient pays out of their own pocket when they have insurance, such as deductibles, coinsurance, and copayments when receiving medical care. The new rule also requires cost sharing for these services to count toward any in-network deductibles and out-of-pocket maximums.

This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.

How Facilities Can Navigate the No Surprises Act with Ready Doc™

If it wasn’t complex enough already, the No Surprises Act added another layer to the spider web of healthcare administration. However, with an all-in-one medical credentialing software such as Ready Doc™, the task is not as daunting.

Healthcare facility administrators can keep track of their provider roster and identify payer enrollment status in one centralized dashboard. Within three clicks or less, administrators can begin the payer enrollment process for individual healthcare providers. This is especially useful if it becomes evident a large portion of patients are seeing out-of-network providers at the same facility covered under their insurance plan.

Ready Doc™ can also handle appointments and privileges. This allows administrators to set specific privileges for a physician based on their healthcare network enrollment status—improving patient care access to the most qualified healthcare professionals enrolled in the largest networks.

Additional Resources:

The Department of Health and Human Services, the Department of Labor, and the Department of Treasury selected several organizations to serve as certified independent, dispute resolution entities to participate in the resolution process involving healthcare providers or medical facilities, and the insurance companies or health plans. If a healthcare provider or medical facility cannot reach an agreement with a health plan on the payment amount for an out-of-network service covered by the rules set forth under the No Surprises Act, one of the specified organizations can be selected to make a payment determination.

There are generally three main steps to the independent dispute resolution process:

  1. The parties mutually select one of the certified independent dispute resolution entities from the federally approved list to decide the payment amount owed by the health plan. Everyone involved must attest to having no conflicts of interest.
  2. The healthcare provider or medical facility and the health plan will submit payment offers to the chosen certified independent dispute resolution entity as well as any additional information supporting their payment offers.
  3. The certified independent dispute resolution entity will select a payment amount from the submitted offers. The healthcare provider or medical facility as well as the health plan must abide by the decision and a payment must be made within 30 calendar days.

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