NO SURPRISES ACT: WHAT HEALTHCARE PROVIDERS NEED TO KNOW

The No Surprises Act, effective January 1, 2022, is designed to protect patients from “surprise bills” – bills for services patients unexpectedly receive from out-of-network (OON) providers in an in-network facility. The law also promotes patient transparency by requiring providers to give good faith estimates of the total cost of expected care to uninsured and self-pay individuals. This law may materially increase administrative burdens on practices and inhibit their ability to bill patients for services. The following are some non-exhaustive examples of how physicians may be affected.

If out-of-network physician provides emergency services at an in-network hospital, that physician may not balance bill the patient. The patient’s payer is required to pay the physician a qualifying payment amount, which is often its median contract rate. If the parties disagree on the payment rate, the law created the Independent Dispute Resolution (IDR) process to assist payers and providers with determining the final payment amount for services. For the calendar year 2022, parties must pay a $50 administrative fee at the time of submission to the IDR, and an IDR entity fee that ranges from $200-$500 for single cases, and $268-$670 for batched cases, respectively.

Physicians providing services to non-emergency patients

If a physician provides services to a patient who is no longer receiving emergency services (the patient is stable, can travel to an available in-network provider, and can receive information and provide informed consent), and that physician is out-of-network at an in-network hospital or other covered facility, the physician must obtain consent from the patient to bill the patient for anything their payer does not pay. The government has provided a sample consent form which explains to the patient that they must provide permission in order to be billed by that physician. Since the patient is in the hospital, non-hospital-based practices will have to determine who from their office can obtain this consent prior to the services being rendered.

Physicians providing services in the office

If a physician provides services to a self-pay or uninsured patient in the office, prior to the services being rendered (there is a schedule for how many days in advance this has to be given to patients) a “Good Faith Estimate” must be given to patients listing the services for their course of care they are expected to receive by CPT code and how much it will cost. If the estimate is more than $400 off, the patient may enter into a fee dispute process.

Practices must also post a notice of patients’ billing protections on their website and in a conspicuous place at the practice. The government has provided a sample notice that can be used.

The No Surprises Act has spurred controversy. The American Medical Association (AMA) and the American Hospital Association (AHA) have filed a lawsuit asserting that certain aspects of the IDR favor payers over providers.