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Don't Be Surprised: The No Surprise Act Explained

January 1, 2022, the Federal No Surprises Act became law. This legislation aims to place requirements on health insurers and healthcare providers designed to protect consumers in surprise billing situations. “Surprise Billing” refers to large, unexpected bills charged to patients by out-of-network providers that may be seeing patients at an in-network facility.

This act refers to two types of situations in which the patient has little to no control over whether an out-of-network provider treats them:

  • Emergencies. The general rule is to go to the closest emergency room. This may or may not be in-network, and it may or may not have out-of-network providers caring for patients. But the patient is not in a position to determine whether the care they’re receiving is in-network. Under the No Surprises Act, consumer protections also extend to hospitalization immediately following emergency room care until the patient can safely be transferred to an in-network facility.

  • Non-emergency situations in which the patient goes to an in-network hospital but is unknowingly treated by an out-of-network provider. For example, you might choose an in-network hospital for your planned surgery but not realize that the radiologist or anesthesiologist, or assistant surgeon isn’t in your insurance network. In some cases, you might never interact with this provider at all.

The No Surprises Act does not apply to situations in which a patient chooses to use an out-of-network provider (as opposed to situations in which the patient had no choice or was unknowingly treated by an out-of-network provider at an in-network facility). So if a patient goes to an out-of-network facility or doctor in a non-emergency situation, balance billing can still be expected, and the insurance carrier's standard rules for out-of-network coverage would still be used.

In limited non-emergency situations, out-of-network medical providers can ask patients to waive their rights under the No Surprises Act. If the patient signs a form indicating they agree to the out-of-network charges, they can still receive a balance bill. And the out-of-network medical provider can refuse to provide treatment if patients don’t waive their balance billing protections.

How does this act affect the group and practice?

  • It applies to all patients who do not have insurance.

  • Groups need to provide patients with an upfront estimate of how much they believe the services being rendered by the provider will cost.

  • It gives your patients the ability to dispute medical bills easily

What must we do to comply with the No Surprises Act?

For groups to avoid penalties and fines, your organization must roll out a process and a workflow to provide good faith estimates to your patient population. A Good Faith Estimate should contain:

  • The patient’s name and date of birth

  • Description of service(s) and diagnosis codes

  • Payment rates for each item of service

  • Frequency of visits

  • Diagnosis – You can put “Unknown” if you haven’t seen the client yet. Then, issue a replacement GFE with the correct diagnosis after the first appointment.

  • Your name, National Provider Identifier, Tax Identification Number (TIN), and the state(s) and office or facility location(s) where you will provide the services

Disclaimer 1 – You need to put a statement on your GFE declaring that it’s only an estimate, not a contract, and doesn’t include unexpected costs.

Disclaimer 2 – This disclaimer lets your clients know that they can dispute a bill if it exceeds the GFE by at least $400

If you want to learn more about the No Surprises Act, contact our team to learn how The Provider Partner has helped physicians navigate changing regulations.

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