The No Surprises Act: What you need to know
Written by: Beth Davis
The federal No Surprises Act is a law that took effect on January 1, 2022. The act seeks to protect consumers from surprise medical bills and requires increased transparency regarding healthcare costs. As a result of this expansive law, there are many new regulations in effect following discretionary delayed enforcement by the Centers for Medicare & Medicaid services (CMS), while other parts of the law are awaiting rulemaking. These regulations will require new processes, workflows and maximized software tools by the majority of industry.
The intent of this article is not to provide legal advice, but to highlight the general content covered in the No Surprises Act with an emphasis on those elements that are most relevant to you now and for which software may be able to assist. Please direct any questions you may have about how the law may impact you to your own legal counsel.
What we know about what’s currently in effect for No Surprises Act:
- Effective 1/1/2022, requires a good faith estimate (GFE) for uninsured/self-pay patients
- Requires a convening provider or facility (one who schedules or receives the request for the primary service) to provide an uninsured or self-pay patient with a GFE upon scheduling a visit or upon request by the patient.
- The GFE is required of all healthcare providers and is not specific to specialty, facility type or sites of service.
- The GFE must be provided to the patient within defined timelines based on how far in the future the appointment is being scheduled.
- The GFE must include specific data elements, such as codified services, must be delivered in the manner requested by the patient and must clearly state the itemized and total cost to the patient (including any discounts, such as financial aid).
- The GFE must be kept on file by the convening healthcare organization for six years.
- While the law says all related co-provider/co-facility services must be included in the GFE given to the patient, CMS has indicated they will exercise enforcement discretion on this portion of the regulation indefinitely pending further rulemaking.
The No Surprises Act also:
- Prohibits billing patients for more than their plan’s cost-sharing amount for emergency care, including certain services delivered by out-of-network providers at an in-network facility. It also requires private health plans to cover these out-of-network claims and apply in-network cost sharing.
- Requires a patient’s informed consent to balance bill when services are provided by an out-of-network provider.
- Requires providers to disclose information regarding balance billing protections and how to report violations. Must post prominently at the location of the facility, public websites and provide to the participant.
- Requires health plans to verify the accuracy of provider information included in the plan’s directory at least every 90 days and calls for providers to respond with updated information as necessary.
- Ensures continuity of care when a provider’s network status changes.
- Enables health plans and providers to negotiate privately over the amount to be paid for any surprise bill, and if they can’t agree, either party can ask for an Independent Dispute Resolution (IDR) process to decide the payment amount.
- Establishes a new final-offer arbitration process in the event an out-of-network provider and the health insurer can’t agree on a payment amount.
- Creates arbitration paths and penalties when the actual service cost is more than $400 higher than the estimate.
No Surprises Act sections that are still awaiting regulations:
- Expanding the GFE requirements to insured patients with group, individual and Federal Employees Health Benefit plans. (Does not apply to federal programs such as: Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or Tricare).
- Requirement that the health plan create and send the patient an advanced explanation of benefits (AEOB) based on the good faith estimates submitted by the convening provider (and potentially including co-provider/co-facility procedures) prior to any scheduled patient visit.
What Veradigm is doing? Veradigm is deeply involved in industry discussion to develop guidelines and recommendations for implementing various sections of the No Surprises Act. We have direct relationships with CMS and they have indicated that they know the GFE regulation for uninsured/self-pay patients is confusing. It offers insufficient time for the industry to adjust and some of the necessary infrastructure to support it is not yet in place. Informal indications from industry-listening sessions are that CMS doesn’t intend to enforce penalties specific to this regulation in the immediate future.
We actively contribute as leaders in several industry groups focused on these regulations:
- Workgroup for Electronic Data Interchange (WEDI): Recognized and trusted as a formal advisor to the Secretary of HHS and has convened multiple stakeholder groups into a task force that provides input and advises government regulators.
- Cooperative Exchange – The National Clearinghouse Association: For input on government regulations in the healthcare industry.
- Electronic Health Record Association: Regularly engages with CMS and other departments of HHS to address areas of concern about regulations affecting software developers and our clients.
- Partner with provider advocacy organizations (AMA, AAFP, MGMA, etc.) in related advocacy.
Look for webinars and blog posts on the for updates and information about how Veradigm products can help. All recorded webinars can be found in the Community Forum for Veradigm® Practice Management under the Veradigm PM Recorded Webinars topic.
April 12, 2023: Veradigm PM and Payerpath - Unwrapping the No Surprises Act
Questions to Consider
- How will I communicate expected services and costs with my co-providers and co-facilities?
- What backend processes and resources are needed to be able to provide diagnosis and procedure code(s) prior to the service being rendered?
- How will I satisfy estimate requirements when I don’t have enough information to produce or codify a GFE?
- How will I track my GFE against the final bill to ensure the estimated cost is not more than $400 different from the actual services rendered?
- How will I provide the GFE to the patient?
- Will the GFE processes and workflows I establish now to meet the uninsured/self-pay GFE requirements be able to be expanded to include the GFE requirements for insured patients when that regulation goes into effect?
- How will I change my appointment scheduling workflows, including appointment reminders, to accommodate the GFE?
Learn More
The No Surprises Act legislation is massive and will impact many of your processes, workflows and tools. Here are a few good resources to get you started:
- Ensure you have a firm understanding of the No Surprises Act and what it can mean for your practice.
- https://www.cms.gov/nosurprises
- https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets
- Requirements Related to Surprise Billing; Part I
- Requirements Related to Surprise Billing; Part II
- Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing
- FAQ clarifying what’s in effect right now related to the GFE for uninsured/self-pay patients.
- cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidance-Good-Faith-Estimates-FAQ
- Check payer and provider organization websites and bulletins to learn what solutions, updates and recommendations are available
- For questions about the provider requirements and provider enforcement email.
- Email: provider_enforcement@cms.hhs.gov
- Information about the Independent Dispute Resolution Process and others.