The No Surprises Act could take many by surprise

Are you operationally ready for the No Surprises Act? Have you implemented the required changes within your practice or facility?

With NSA regulations now in place, it’s time to act if you are:

• a qualified healthcare professional providing services to patients who are uninsured, choose not to file a claim, or receive non-covered or out-of-network services
• a physician who provides emergency services in an out-of-network facility
• a physician who provides emergency services to patients whose insurance is not among your contracted companies

The NSA is federal legislation that went into effect January 1, 2022, to address surprise patient billing. More specifically, according to the U.S. Centers for Medicare & Medicaid Services (CMS), the law will “restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.”

Supporters say it’s a compromise intended to satisfy patients and providers. But the American Hospital Association, the American Medical Association, and others have filed suit arguing that the act unfairly benefits insurers. According to the groups, they don’t seek to challenge the law’s intent to protect patients, but instead, they say they want to challenge the NSA rules that regulate negotiations between insurers and providers.

Who does the NSA affect?

The NSA will impact billing practices for hospitals, hospital outpatient departments, critical access hospitals, free-standing emergency departments, ambulatory surgery centers, and air ambulance services for out-of-network providers. Ground ambulance services are not affected.

In addition, any provider who offers services to a patient treated at one of the facilities above (i.e., anesthesiology, assistant surgeons, pathology, radiology, neonatology, and diagnostic services performed by any provider) will be affected. The regulations are not limited to Medicare-participating providers.

What does the NSA address?

The new law has a far-reaching impact on a variety of services, including emergency and non-emergency – all of which went into effect on January 1. Some of the changes include:

• Notice of patient consent is now required for self-pay patients who receive non-emergency services.
• A “no exception group” of providers and services includes anesthesiologists, radiologists, neonatologists, emergency medicine providers, pathologists, diagnostic testing, as well as other services provided by hospitals, intensivists, and assistant surgeons. Patients do not typically choose these types of providers or services and are often unable to request a notice of patient consent for non-emergency services.
• The qualifying payment amount (QPA) is determined by a plan’s 2019 median in-network rate paid for the same or similar service in a specific geographic area.
• The creation of an independent dispute resolution rule will help determine how much a health plan must pay an out-of-network provider.
• There are additional requirements to be considered when providing services to a self-pay patient.
• Good faith estimates (GFE) were established for patients who receive non-emergency services.
• A patient-provider dispute resolution process is now in place for patients who receive a good faith estimate but then are billed at least $400 more than listed on the GFE.
• Surprise billing and GFE information notice must be posted at each physical location as well as through a clear link on the provider’s website.

The NSA will lead to big changes for healthcare providers and medical facilities, but we can help you sort through the law and its compliance requirements. Reach out to me or a member of our healthcare industry team for help.

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