The No Surprises Act 2022 is around the corner, and it should come as no surprise that it’s going to be a game-changer in how you bill and collect from patients. Although well-intentioned and with good reason, the No Surprises Act 2022 will be challenging to maneuver.
What is the No Surprises Act 2022?
The No Surprises Act comes into effect from January 01, 2022. Its implementation means that:
a. Patients can no longer be held accountable for emergency services from out-of-network providers or out-of-network hospital services (including ambulance services and emergency room physicians).
b. Patients can no longer be held liable for ‘balance billing’ by an in-network healthcare facility for services received from out-of-network (OON) providers (such as radiologists, anesthesiologists, pathologists, or neonatologists).
How the No Surprises Act 2022 Impacts Providers
Laws on surprise medical billing already exist in most states. Therefore, the new federal law must be viewed in cohesion with the laws of the State your medical practice is located. Violations can expose you to federal monetary penalties of up to $10,000.
There is a notice and consent process for non-emergency services delivered by an OON provider or healthcare facility. The exception is for non-emergent healthcare services and is only applicable when the patient agrees to bear the cost of an OON provider. Also, the medical practice should obtain written consent from the patient at least 72 hours before the service.
The payments by healthcare plans for emergency services at an OON healthcare entity or by an OON provider will be basis the ‘qualified payment amount’ or the QPA. The QPA will be the insurer’s median in-network contracted rate for similar services in that geographic region.
If the provider disagrees with the payment received from the healthcare plan, or if the claim is denied, an arbitration process called the IDR (Independent Dispute Resolution) can be initiated. However, the practice will bear the burden of proof to justify the demand for a higher payment for the disputed claim.
For an in-depth understanding of the implications, watch PracticeForces co-founder and HBMA board member Kunal Jain discuss the No Surprises Act with Bill Finerfrock (President of Capitol Associates Inc) and Matt Reiter (Vice President of Capitol Associates Inc).
How Can Providers Prepare for the No Surprises Act
Health care facilities and providers should take the following measures to ensure they are ready for the revenue implications of the No Surprises Act.
1. Streamline the pre-service process.
The combination of increased patient liabilities and the new Act makes it imperative to improve the efficiency of your revenue management process. With most claim denials resulting from a lack of accuracy in the pre-service stage, ensure that your staff is well trained on patient information capture, insurance prior authorization, and medical coding processes.
2. Pricing transparency
The No Surprises Act reinforces the requirement for ensuring complete pricing transparency. Review the pricing list of your healthcare services to ensure that the information is up to date and comprehensive.
While ABN is limited in use, it is undoubtedly a payment safety net for collecting payments for certain medical services. ABNs also ensure that your patients are informed about the cost of medical service and their financial liability before opting for it.
4. Provide an ‘explanation of benefits’ document to the patient (EOB).
An EOB by a provider must, among other information, include the following three essentials:
- A good faith estimate of the cost of service.
- Information of pre-authorization obtained.
- A good faith estimate of the patient’s liability.
- A list of in-network provider(s) at the medical practice/ healthcare facility.
A declaration of whether the provider is out of network and alternatively the list of participating providers at the facility.
5. Understand the guidelines of the Informal Dispute Resolution (IDR) process.
There are provisions in the new Act that have been designed to protect the interest of the providers. For instance, providers may find it unfeasible to seek arbitration for single and small value disputed claims. As suggested by Matt Reiter in the HBMA live discussion, you have the option of clubbing disputed claims for a specific provider in a single arbitration discussion. Therefore, you must take the time to understand how the arbitration process works.
Being prepared for the upcoming regulatory and compliance changes will be vital to the health of your practice revenues in 2022. If you need assistance with enhancing your medical billing, patient collections, or claims management processes, we would be happy to help.
Contact us now to book a free consultation.