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Guide to the No Surprises Act in 2022

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Over two-thirds of adults say they worry about unexpected medical bills — and their fears are well-founded. A big portion of healthcare claims involves at least one out-of-network bill, including one in five emergency claims and one in six in-network hospitalizations. The No Surprises Act went into effect in January 2022, helping many Americans breathe a sigh of relief. It can help patients avoid hundreds if not thousands in unexpected care costs, but it does change things for providers and health plans. These organizations must change their billing practices to avoid violating the new ruling.

The No Surprises Act is an important part of improving population health overall and reducing the growing problem of healthcare debt. Although it complicates things for providers and plans, it can help improve the patient experience and encourage more people to seek care without the threat of medical bills hanging over their heads.

Let’s explore this timely medical billing law and how the No Surprises billing act affects healthcare practices.

What Is the No Surprises Act, and How Does
It Work?

To help eliminate unexpected medical costs for patients, the No Surprises Act changed several aspects of healthcare billing. Many patients unknowingly receive care from providers who are out of their health insurance networks, leaving them with charges that are much higher than they anticipated. Considering medical debt for Americans exceeds $195 billion, and many families wouldn’t be able to pay a $2,000 medical bill, this law can make a big difference.

Public health insurance programs like Medicare, Medicaid and Medicare Advantage already have surprise billing protections. The No Surprises Act delivers similar protections to patients with commercial insurance or without insurance at all. The No Surprises Act amended the Public Health Service Act (PHSA) to change how providers, facilities and insurance providers must handle billing processes. It is part of the Consolidated Appropriations Act of 2021.

Here are some of the main changes that came from this legislation.

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1. No Balance Billing for
Out-of-Network Patients

Balance billing refers to charging the patient the difference between the provider’s charges and the amount allowed by the patient’s insurance. The No Surprises Act bars providers from balance billing out-of-network patients in some situations. A provider or facility cannot balance bill for:

  • Out-of-network emergency services performed by an emergency room not contracted with the patient’s insurance. Some types of nonemergency care delivered at certain facilities are also included in the balance billing prohibition, including care provided in hospital outpatient departments, critical access hospitals and ambulatory surgery centers (ASCs). Some post-stabilization services are also considered emergency services under this prohibition.
  • Out-of-network air ambulance services provided by an air ambulance company not contracted with the patient’s insurance. Ground ambulance services are not included in this prohibition.
  • Out-of-network services performed at in-network facilities. These are services performed in facilities contracted with the patient’s insurance but performed by providers not contracted with the patient’s insurance. This often occurs at hospitals that contract with provider groups such as anesthesiology and imaging groups outside the insurance network.

In these situations, a provider can only collect the in-network portion of the patient’s bill and cannot charge for the remainder not covered by the patient’s insurance.

In some situations, providers can still balance bill, but several conditions must be met. Patients may be exempt if:

  • The treating provider or attending emergency physician determines that the patient can travel to a participating provider with nonmedical or nonemergency medical transportation.
  • They are in a condition to provide informed consent and receive notice to be balance billed.
  • The facility or provider also satisfies applicable state requirements.

2. Coverage for Emergency Services Without Prior Authorization

Insurance companies must cover emergency services without prior authorization for both in-network and out-of-network facilities.

3. Good Faith Estimates

Self-pay and uninsured patients are entitled to good faith estimates (GFEs) under the No Surprises Act. GFEs should include all items or services reasonably expected to be delivered with the item or service. Information should include the expected charges, services and diagnostic codes. Providers must issue these estimates at least one day before the service and post notices about patient rights to GFEs. The Centers for Medicare and Medicaid Services (CMS) have created a model disclosure notice for practices to use, including plain-language information on patient rights under the No Surprises Act and relevant regulations.

The process for providing GFEs differs depending on the type of provider:

  • Convening providers: Convening providers receive the initial request for the GFE and are responsible for scheduling primary services. These providers must ask about a patient’s method of coverage. If the patient is uninsured or self-paying, the convening provider must furnish a GFE. Notices about GFE availability must be posted in the provider or facility’s office, on their website and on-site wherever cost or scheduling questions may appear.
  • Co-providers: These providers furnish items or services alongside the primary service. Co-providers must issue the GFE within one business day after the convening provider or facility requests it. They must update the GFE if the scope of care changes. If a patient directly requests an estimate or schedules a service from a provider usually considered a co-provider, that provider is considered a convening provider.

These providers must also follow specific rules regarding what kind of information they provide and how long they need to retain the document.

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4. Dispute Resolution

In surprise billing situations, providers still need to get paid for their work. That’s where dispute resolution processes come in. In many cases, an individual state’s surprise billing law provides direction. If the state does not have a surprise billing law or more detailed support is needed, providers can utilize the Independent Dispute Resolution (IDR) process. IDR helps providers, payors and facilities determine how much a payor must pay an out-of-network provider or emergency facility for services that fall under balance billing restrictions. 

For patients, uninsured individuals can implement a patient-provider open dispute resolution process if their bill is significantly higher — $400 more than — the GFE.

Currently, the Department of Health and Human Services (HHS) hasn’t developed requirements for GFEs for insured individuals, but these may appear in the future.

In many cases, providers can still charge balance bills if they collect patient consent to do so. Notices must include an estimate of charges and be furnished three or 72 hours before the appointment, depending on when it was scheduled.

Some services are excluded from the consent options. If an out-of-network provider performs services in an in-network hospital or ASC, they cannot balance bill. These services include:

  • Emergency medicine, pathology, anesthesiology, radiology and neonatology items and services provided by either physician or non-physician practitioners.
  • Services and items provided by hospitalists, assistant surgeons and intensivists.
  • Services and items provided by nonparticipating providers if a participating provider is not available to deliver the item or service at the facility.
  • Diagnostic services, including laboratory and radiology services.
  • Services or items provided as a result of urgent, unforeseen medical needs that appeared when the service or item was delivered, even if balance billing consent was obtained.
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How Will the No Surprises Act
Affect Providers?

Providers take on the bulk of the responsibility for the No Surprises Act. If you’re a provider, this legislation likely affects:

  • Balance billing procedures: You’ll need to ensure your billing practices include measures that check for prohibited balance billing and outline dispute resolution if patients receive these charges.
  • Price transparency: Staff must be trained on the rules of the No Surprises Act so they can provide pricing and respond to concerns appropriately. This includes how they respond to certain “trigger phrases” that indicate the need for action to abide by the new requirements.
  • Estimation procedures: An estimation tool can help your team quickly create and deliver accurate GFEs. Your practice may work with many codes and charges, and a robust estimation tool can help you organize them into compliant GFEs.
  • Notices: You must also post notices about patient rights under the No Surprises Act in your practice and on your website. Create documentation you can distribute to applicable patients and health plans.
  • Retention policies: Include GFEs, notices and consent forms in your retention policies according to the length of time that applies to your practice.
  • Disputes: If a patient disputes a charge, you’ll need to be prepared with the GFE, the bill and supporting documents that explain the difference between the two. You’ll need to understand the dispute process for your organization, including whether you’ll be coordinating with state or federal portals and any limitations regarding moving a bill into collections, collecting late fees or threatening retaliatory action.
  • Continuity of care policies: If a provider or facility changes their network status, they are expected to help facilitate the continuity of care of patients who were previously in-network. They may need to accept payment from the plan or issuer according to the previous contract for up to 90 days after the patient received notification about the change in status. The provider or facility must also behave as if the contract were still in place by following applicable procedures, policies and quality standards.
  • The accuracy of provider directories: To improve provider directories, providers and facilities must frequently submit information to a plan or issuer. They’ll need to update the other party when network agreements start or end, significant changes occur, the plan or issuer requests it or when the provider, facility or HHS deems it appropriate. If the directory is inaccurate and a patient pays more as a result, the provider or facility is in charge of reimbursing them.

The No Surprises Act allows HHS to fine providers with civil monetary penalties of up to $10,000 per violation, so staying ahead of these requirements can help you avoid big financial hurdles and maintain your patients’ trust.

How Will the No Surprises Act Affect Payors?

Health plans also have some new responsibilities under the No Surprises Act:

  • Payment processes: Under the new rules, prohibited payments can’t be billed to the patient. Instead, the payor needs to either send an initial payment or notice of denial to the provider within 30 days. An initial payment or qualifying payment amount (QPA) is determined by rates in the geographical area and insurance market for that service. If the provider thinks this amount is insufficient, they can open a 30-day open negotiation to identify a mutually agreeable payment amount. If the two don’t come to an agreement, the provider can initiate a final offer arbitration in which an independent arbitrator selects from the “final offer” from each party. Plan issuers need to be aware of this change and prepare for it.
  • Advanced Explanation of Benefits (EOB): The No Surprises Act also requires plans to send Advanced EOBs for services scheduled at least 72 hours before the service or whenever the member requests it. These EOBs contain information such as the provider’s network status, the GFE from the provider or facility and a GFE of what the health plan will pay.
  • Directory integrity: Payors are also responsible for creating dependable provider directories. Health plans should frequently verify accuracy and regularly assess provider status to provide an up-to-date directory.

How Will the No Surprises Act Affect Patients?

The No Surprises Act doesn’t change much about the typical patient experience besides introducing the GFE, new notices and, potentially, a consent form to balance bill. If they think there is an error in their bill, the process for fixing it should be simple on the patient’s end — the No Surprises Act aims to leave the patient out of payment disputes. Still, simply informing your patients of the No Surprises Act can help ease their concerns about costs for a better patient experience. You can use it to boost their trust in your facility since they know you’re doing your due diligence to ensure they won’t receive any surprise charges.

Stay Ahead of the No Surprises Act

The No Surprises Act might make things easier on patients, but it could create some unpleasant surprises for providers if they aren’t prepared for it. Your billing system needs to be ready for the nuances the No Surprises Act has introduced, including supporting your patients before and after their appointments. Before care, you’ll need to check some boxes, like asking about their insurance coverage and providing notices or GFEs. After their appointment, you’ll need to ensure the patient is billed correctly, in line with the rules from the No Surprises Act. And all of this must happen while providing a stellar customer experience, complete with easy-to-access payment options and customer support.

Millennia Complete is a comprehensive platform for end-to-end support across the entire patient journey. With Millennia Access and Millennia Recover, you can streamline the whole patient experience with a user-friendly portal and a wide array of tools, like scheduling, check-ins, payment processing and real-time analytics. With artificial intelligence, machine learning and various automation tools, you can eliminate repetitive processes and optimize your billing practices to stay on top of the No Surprises Act and improve patient engagement. Our concierge services include U.S.-based agents who are well-trained on the No Surprises Act and specific trigger phrases.

Request your consultation today to see Millennia Complete in action and learn more about how we help you handle the No Surprises Act.