No Surprises Act – Medical Provider Compliance

 

Effective January 1, 2022

Purpose: “Protects individuals from surprise medical bills for emergency services, air ambulance services provided by out-of-network providers, and non-emergency services provided by out-of-network providers at in-network facilities in certain circumstances”

NOTE: These requirements do NOT apply to beneficiaries or enrollees in federal programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE

Uninsured/Self-Pay Patient

  • Provide a good faith estimate of expected charges for items and services that are to be provided in conjunction with the primary item or service. This can be done by providing a fee schedule during intake paperwork and/or posting it publicly. 

Out of Network Providers

Emergency Services

  • Prohibited from balance billing for amounts beyond what the patient would have been required to pay if the services had been delivered in-network

Non-Emergency Services and Patients Who Wish to Use an Out of Network Provider

  • Timeframe of when to provide this notice:
      • 72 hours prior if the patient made an appointment at least 72 hours before the date that the items and services are to be furnished
      • Day the appointment is scheduled if the patient makes an appointment for the relevant items or services within 72 hours of the date the items and services are to be furnished
      • No later than 3 hours prior to furnishing the relevant items or services if the patient is provided the notice and consent documents on the day the items or services are to be furnished

General

  • Disclose balance billing protections and how to report violations (post this information prominently at the location of the facility, on the website, and provide it to the participant) – Use this model notice that CMS has provided (pages 2-4)
  • In the case of a dispute between a plan and an out-of-network provider, regarding the amount to be paid by the plan, a 30-day open negotiation period is required. This starts on the day of initial payment or notice of denial of payment and involves trying to mutually agree on a payment rate before initiating the Independent Dispute Resolution process. 

In a situation where an uninsured or self-pay patient receives a good faith estimate and then is billed for an amount substantially in excess of the good faith estimate, there is a patient-provider dispute resolution process to determine a payment amount. This can be achieved by a dispute resolution clause, such as mediation or arbitration inside your patient intake paperwork, or a separate policy. Transparent and clear billing practices will also prevent surprise billing.

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