What is the No Surprises Act?

What is the No Surprises Act?

The No Surprises Act (NSA), is a federal law that applies new measures to protect Americans who receive emergency and non-emergency care at in-network facilities. Introduced by Congress in January 2020 with a rollout date of January 2022, the law provides updated billing protections when receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect these patients, excessive out-of-pocket costs are limited, and certain emergency services must be covered without any prior authorization, regardless of whether or not a provider or facility is in-network. The law also provides for an independent dispute resolution process that plans to help settle outstanding billing and payment issues.

What does all of this mean for your facility? Let’s dig into some of the basics behind the No Surprises Act.

What is Balance Billing?

Previously, in addition to any out-of-network cost-sharing a patient might owe, the out-of-network provider or facility could bill for the difference between the billed charge and the amount a health plan paid unless banned by state law. This is “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

What Qualifies as a “Surprise Medical Bill?”

A surprise medical bill is simply a bill for any difference between the charges the provider bills, and the amount paid by the consumer’s health plan. These usually occur when the patient didn’t select the provider by choice or didn’t know they were out-of-network.

Previously, if consumers had health coverage and got care from an out-of-network provider, their health plan usually wouldn’t cover the entire out-of-network cost. This left many with higher costs than if they’d been seen by an in-network provider. A 2020 Peterson-KFF Health System Tracker study found that 15% of non-elderly adults in the United States reported having difficulty paying medical bills, and that percentage will continue to climb as the COVID-19 pandemic continues across the country.

What Does the Payment Dispute Resolution Process Look Like?

So, what happens when a patient begins a payment dispute resolution? When a provider or facility gets a payment denial notice or an initial payment from a health plan for particular out-of-network services, either the health plan or the provider can decide to start an open negotiation period that lasts 30 business days. At the end of the 30-business-day period, if the health plan and provider or facility haven’t reached an agreement, either party can begin the independent dispute resolution process.

According to the CMS rules, the independent dispute resolution process:

• Brings in a third party known as a “certified independent dispute resolution entity” to decide the payment amount. The parties mutually select the certified independent dispute resolution entity, and everyone involved must attest to having no conflicts of interest.
• Requires the provider or facility and the health plan to submit payment offers to the certified independent dispute resolution entity and additional information supporting their payment offers.
• Requires the certified independent dispute resolution entity to select from the payment offers. Both the provider or facility and the health plan must abide by the certified entity’s decision, and payment must be made within 30 calendar days.

What’s Protected and What’s Not?

The NSA does not offer consumers federal protections against surprise bills for non-emergency services provided in other facilities such as birthing centers, clinics, hospices, addiction treatment facilities, nursing homes, or urgent care centers. Patients are also already protected against surprise medical billing if they have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. The NSA does protect against surprise billing from most emergency services, post-emergency stabilization services, and non-emergency services at in-network facilities.

How Will the No Surprises Act Directly Affect Your Facility’s Revenue Cycle?

Healthcare providers, facilities, and air ambulance providers will be required to give uninsured (or self-pay) individuals good-faith estimates of expected charges for scheduled health care services and may have to participate in a patient-provider payment dispute resolution process if their billed charges are higher than the good-faith estimates.

Providers and plans also must notify consumers of their surprise medical bill protections. It is now required for providers and facilities to post a one-page disclosure notice summarizing NSA surprise billing protections on a public website and give this disclosure to each patient who received NSA-covered services. This notice must be supplied no later than the date when payment is requested, though the regulation specifies it is not required to be included with the bill itself. Health plans are also required to provide consumers the disclosure notice with every EOB that includes a claim for surprise medical bills.

The Congressional Budget Office estimates that the No Surprises Act may reduce health insurance premiums by up to 1% – these lower costs for health insurance would reduce the amount patients and the government would have to pay to insurers. As the future of the healthcare revenue cycle changes, it is going to be essential for healthcare providers to remain compliant with these new federal laws in order to maintain healthy revenue integrity.