In January 2022, the Centers for Medicare and Medicaid Services established and implemented the No Surprises Act. As with all medical legislation, providers, and practice, owners must understand the No Surprises Act to ensure coding and billing procedures compliance.
The team at Larsen Billing breaks down the No Surprises Act, providing insight into how the act will affect your practice and office workflows.
Understanding the No Surprises Act
As its name suggests, this act prevents patients from being surprised by their medical bills. The following requirements are foundational to the No Surprises Act and can be found through CMS:
- Providers and facilities are prohibited from directly billing individuals for the difference between the amount they charge and the amount that the individual’s plan or coverage will pay plus the individual’s cost-sharing amounts in certain circumstances;
- Providers and facilities are required to provide good faith estimates of charges for care to uninsured (or self-pay) individuals upon scheduling care or on request, and for individuals with certain types of coverage, to submit good faith estimates to the individual’s plan or issuer;
- Billers must create a patient-provider dispute resolution process for uninsured (or self-pay) individuals to contest charges that are “substantially in excess” of the good faith estimate;
- Certain providers and facilities must publicly disclose restrictions on balance billing; and
Billed amounts are limited when a provider’s network status changes mid-treatment or individuals act on inaccurate provider directory information.
Even if your practice doesn’t bill government payers, this act still applies to you since any provider with any cash-pay patients must comply.
No Surprises Act Good Faith Estimates
Effective January 1, 20202, the No Surprises Act protects uninsured or self-pay patients with Good Faith Estimates (GFEs) of their medical bills. GFEs provide a realistic estimation of a patient’s costs before they receive the item or service.
Delivering A Good Faith Estimate
These estimate requirements apply to providers caring for self-pay or uninsured patients. In addition, providers must give written estimates delivered by hand or digitally before the service is rendered.
You’re required to ask new patients if they plan to utilize insurance benefits, whether in or out-of-network. If they say yes, you are not required to provide a GFE, but it’s still best practice to do so, and legislation may be coming soon that will require that.
Posting Good Faith Estimates
Information regarding the availability of a GFE must be posted at the front desk area and on your website.
GFE Forms and Template Requirements
For patients planning to pay out-of-pocket, providers must supply a GFE; the GFE must be in the medical record. You can find a GFE template through CMS.
It’s important to note that if you currently provide a financial agreement to your patients that discloses all your fees, this is a type of GFE. The template that CMS provides is an example of what your agreement could look like. To ensure your current financial agreement fulfills the GFE requirements, update it to include the DX codes and NPIs of all care providers, the NPI for the professional/facility group, and the EINs for your practice.
You should also include the wording from page 8 of the CMS template in your GFE/financial agreement. We recommend that your attorney review any form you use as a GFE to ensure it complies with this new law.
If providers charge over $400 more than the estimate, patients have the right to dispute the bill; if the care changes and the cost increases, providers must provide an updated GFE. Additionally, if the diagnoses change and the cost of care is affected, an updated GFE is required.
Providers can create a recurring GFE for repetitive care. These GFEs should be updated at least annually.
Deadlines for GFEs
Deadlines for GFE delivery vary according to when the patient schedules their appointments. However, we provide the delivery timelines below:
- For patient appointments scheduled ten business days in advance, your practice must provide a GFE within three business days of the appointment.
- Appointments from three to nine business days in advance require a GFE within one business day.
- No advance estimates are required for appointments scheduled fewer than three business days in advance.
- Practices must provide GFEs to patients requiring them within three business days.
Balance Billing Limitations under the No Surprises Act
Balance billing does not refer to collecting deductibles, coinsurance, and copays. Balance billing relates only to the difference between billed and allowed amounts. In-network providers cannot collect this difference; out-of-network providers/facilities can collect in some states. Many states prohibit collecting the difference, but the No Surprises Act determines what practices are allowed to collect.
Out-of-Network Providers and Balance Billing
Out-of-network providers can’t balance bills for non-emergency services performed in an in-network facility. This applies to hospitals and ambulatory surgical centers, including birth centers.
Patient Consent to Wave Balance Billing Protections
Providers and facilities may never seek a patient’s consent to waive the No Surprises Act’s balance billing protections for non-emergency services when services are provided due to unforeseen urgent medical needs or are banned by state laws.
Providers and facilities may use the notice-and-consent exception to get a patient to voluntarily waive their balance billing protections for non-emergency services furnished in an in-network facility.
The No Surprises Act doesn’t regulate balance billing for non-emergency services when provided in an out-of-network facility or when the services provided are not covered under the in-network terms of the patient’s plan. Out-of-network providers and out-of-network facilities may provide notice and get signed consent from patients to waive balance billing protections.
Balance Billing Consent Delivery
If an appointment is scheduled at least 72 hours before the appointment date, the notice/consent forms must be furnished no later than 72 hours before the appointment date; otherwise, the documents must be given on the day the appointment was made and at least 3 hours before the appointment.
Notice/consent documents must be separate from other forms and be delivered on paper or electronically, according to patient preference.
A provider can refuse to treat a patient if they don’t consent to waive balance billing (if allowed by state law,) but the provider can’t impose fees for canceling care because of it.
The No Surprises Act and Your Practice
The No Surprises Act brings many new regulations and guidelines that will affect your front-office protocols. That means you must stay abreast of legal changes that affect your billing and coding procedures.
At Larsen Billing, we know that you want to devote your time to the things that matter most to you: patient care. But you can’t ignore medical legislation like the No Surprises Act (among many other changing legislations and regulations).
The team at Larsen Billing keeps up to date with all medical legislation, so you don’t have to. Our talented team of billing and compliance experts ensures your practice maintains compliance and executes patient billing and paperwork correctly the first time.
Reach out today to learn how our billing experts can help your office run smoothly, maintain compliance, provide exceptional patient experiences, and receive the compensation you deserve for your services and care.