The federal No Surprises Act, part of the Consolidated Appropriations Act of 2021, took effect on January 1, 2022. Congress passed the Act in response to years of consumer complaints regarding surprise bills from out-of-network providers after receiving treatment at an in-network facility.
The Act serves to protect consumers from surprise medical bills under a variety of circumstances. What do healthcare providers need to know?
Guidance regarding emergency services
The Act notably bans three items for consumers with health insurance:
- Surprise bills stemming from emergency services from an out-of-network provider. Prior authorization is required.
- Out-of-network coinsurance, copayments or other forms of cost-sharing for all emergency services, as well as some non-emergency circumstances.
- Certain out-of-network charges for additional care by out-of-network providers when at an in-network facility.
Rules regarding out-of-network providers are both complex and controversial and have already faced legal challenges.
What if you don’t provide emergency services?
Practices that don’t provide emergency services are not exempt from changes. The Act also includes regulations regarding patients who are uninsured or wish to self-pay for services. Notably, providers must provide a “good faith estimate” of charges for the patient prior to the service.
Providers must first ask the patient whether they have health insurance and if so, if they seek to submit the claim to their insurance provider. If the patient is either uninsured or wishes to pay out of pocket, the provider must then inform the patient that they can receive a good faith estimate.
What to know about good faith estimates
Information regarding good faith estimates must be clearly visible on the provider’s website, as well as in the physical office. Estimates should be provided in the format requested by the patient or representative, whether on paper or in a digital format. Individual estimates must include the following items, among others:
- The patient’s name and birth date
- Description of the service and scheduled date, as well as a list of other services to be performed along with the primary service, if applicable
- Expected charges of the services
- Names, locations and identifiers of each provider, including NIP and TIN
Several disclaimers must also be included. These include stating that additional services not included in the estimate may be recommended, that actual charges may exceed the estimate, that the estimate is not a contract and that the patient may take action if actual charges substantially exceed the estimate.
When to provide the estimate will be dependent on how far out the service is scheduled. For example, the estimate must be given within one business day if the service is scheduled just three business days out but within three business days if the service is scheduled ten business days out. If a patient requests an estimate at any time, the provider must provide this within three business days.
Other critical information to know
Good faith estimates can quickly become complicated when other services and other providers are involved. For example, a surgery might also include estimates from anesthesia, prescription drugs and more.
As the No Surprises Act is fairly new and has many moving parts, providers will want to carefully examine how this affects their practice and whether they need to make substantial changes to their operations. An experienced healthcare law attorney can provide critical guidance.