Don’t get caught off guard with the No Surprises Act.

Effective since Jan. 1, 2022, there is a new rule that ophthalmic professionals should know: the No Surprises Act.

This act was created to protect patients from devastating medical billing surprises. While most practices already inform self-pay and surgery patients of their financial responsibility in advance of receiving services, now is the time to learn the specifics of the rule and start creating appropriate compliance policies before it becomes widely enforced (read: penalties may begin).

The rule

As part of the Consolidated Appropriations Act of 2021, the No Surprises Act requires self-pay, uninsured, and out-of-network (OON) patients receive advance estimates for non-emergency care. To encourage that, the Requirements Related to Surprise Billing; Part I guidelines¹ state healthcare providers, facilities, and air ambulance services must ensure they are:

• Not balance billing patients for OON emergency services;
• Collecting only in-network patient cost-sharing amounts for all services within an in-network facility, no matter the provider’s network status; and
• Providing notice and obtaining consent for non-emergent services by OON providers working in in-network facilities.

Meanwhile, the Requirements Related to Surprise Billing; Part II guidelines² add the following items:

• Independent dispute resolution. A comprehensive process triggered by the patient applying to services when balance billing is prohibited, as well as contested good faith estimates.
• Good faith estimates for uninsured (or self-pay) individuals. When scheduling an item or service, or if requested by an individual, providers and facilities must inquire about the individual’s health insurance status or whether the individual is seeking to have a claim submitted to insurance for his or her care. The provider or facility must provide a good faith estimate of expected charges for items and services to an uninsured (or self-pay) individual. This good faith estimate must include anticipated charges for items and services expected to be provided together, meaning combining provider and facility fees. The threshold published for an acceptable estimate is within $400.

While compliance is already in effect for the No Surprises Act, the Department of Health and Human Services will exercise enforcement discretion for this first year as providers and facilities develop systems for compliance.³

Creating compliance protocols

To comply with the No Surprises Act requirements, consider creating the following policies:³

• No balance billing for OON emergency services;
• No balance billing for non-emergency services by nonparticipating providers at certain participating healthcare facilities, unless notice was provided and consent obtained;
• Disclose patient protections against balance billing (eg, related information including your financial policy or registration packet as well as required posting in practices and on websites);
• Provide the good faith estimate in advance of scheduled services or upon request for uninsured or self-pay individuals, while making sure to revisit the original estimate if more services are advised;
• Ensure continuity of care when a provider’s network status changes; and
• Improve provider directories and reimburse enrollees for practice errors.

Get started now

While future regulatory guidance is expected for the No Surprises Act, I suggest practices immediately begin to work on developing processes to increase price transparency. This involves ensuring patients understand the practice’s financial policy upon intake, receive cost estimates, give consent for all procedures, and, most importantly, get estimates for all non-emergent services before they are provided if the patient is self-pay, uninsured, or OON. OP

REFERENCES:

1. Requirements Related to Surprise Billing; Part I. CMS-9909-IFC. https://www.govinfo.gov/content/pkg/FR-2021-07-13/pdf/2021-14379.pdf . Accessed Dec. 30, 2021.
2. Requirements Related to Surprise Billing; Part II. CMS-9908-IFC. https://www.govinfo.gov/content/pkg/FR-2021-10-07/pdf/2021-21441.pdf . Accessed Dec. 30, 2021.
3. Overview of Public Health Service (PHS) Act Provider and Facility Requirements. CMS. https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf . Accessed Jan. 6, 2022.