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  • Writer's pictureRMK HOLDINGS INC.

How to Prepare for the No Surprises Act

Updated: Sep 29, 2022

Is your practice prepared for the No Surprises Act? The regulation, signed in 2020, will be implemented starting January 1st, 2022 for healthcare providers and facilities. The No Surprises Act was passed to protect patients and prohibits out-of-network providers from sending them surprise medical bills.

A surprise bill is a balance between your service charge and the amount paid by the patient’s insurer. It could also be a medical bill you send to a patient when their insurer denies their claim because the plan does not cover the procedure.

Why this act? One reason is industry studies show one in five people who visit the emergency room or have an in-network hospitalization get a surprise medical balance bill. This contributes to medical bill balances being one of the major causes of US bankruptcies.

Federal protection from balances applies to most emergency care situations and non-emergency services provided at in-network facilities unless the provider follows the notification and consent process. This is a complex law with enforcement at both federal and state level. The law also extends to group health plans, health insurance issuers, plans under the Federal Employee Health Benefits Program, and air ambulances.

What the No Surprises Act Means for Your Practice

Here is how the No Surprises Act changes the way you bill patients when you don’t have an agreement with their insurance company.

No Sending Surprise Bills to Patients Unless You Have Your Patient’s Consent

With the No Surprises Act, you can no longer send medical bills to patients whose insurers do not cover their entire bill because you are out of network. That is, you can’t send patients the balance of their bill after their insurer pays the covered amount. In essence, you cannot charge more than an in-network provider would charge for the same service.

For non-emergency services, a patient must be informed by written notice and give voluntary consent to utilize a non in-network provider. There are conditions where the consent waiver wouldn’t apply so ensure you put strategies in place to prevent violating the No Surprises Act, as it can cost you up to $10,000 in penalties per violation.

Negotiating Payment with Insurers

Surely, being unable to bill patients for the service you provide means a loss in revenue. However, the No Surprises Act provides an option for you to negotiate with insurers. But, negotiation has to be done within 30 days of the payment dispute.

If you are unable to negotiate a new payment amount with the insurer, the dispute can be taken to an independent arbitrator to resolve it. The arbitrator will consider factors such as the insurer’s median in-network cost, market share, and other factors to decide upon the final payment.

Tips to Prepare for the No Surprises Act

With the No Surprises Act implementation starting in January 2022, these tips will help you stick to the law and still get paid for your services.

Improve Your Revenue Cycle

How you manage your revenue cycle can help you prevent surprise bills incidence. Patient identity errors, mistakes in insurance details, and coding errors are revenue cycle problems that cause claim denials and result in sending surprise bills to patients.

So, ensure that you improve your revenue cycle management to prevent errors. Some of the things you can do include capturing accurate patient data, verifying insurance details, and obtaining authorization before providing services.

Train Staff for the No Surprises Act

Educate relevant staff on the No Surprises Act and how to avoid inadvertently breaching the law. Ensure you train on how to conduct accurate insurance verification, use price transparency tools, and the written consent and waiver process.

Also, your staff should know how to and feel comfortable interacting with patients concerning their medical bills. Billing disputes are often the cause of poor patient experiences. Your team should be able to clearly communicate the billing situation to patients, as well as obtain advance consent (ensuring to meet all parameters of the consent and waiver process) for out-of-network services.

Get Advance Consent for Balance Bills

The No Surprises Act gives room for you to send a balance bill to a patient in specific situations provided that they agree to use your service despite being out-of-network. That is, you should get consent from the patient to bill them the cost of the service.

Protect yourself and your practice from the No Surprises Act and avoid losing revenue. Ensure that you or your staff get consent from patients in applicable situations. Moreover, the patient has to agree to a balance bill at least three days before the service you provide.

(Read how the AMA is helping medical providers receive fair reimbursement under the No Surprises Act.)

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