The No Surprises Act: What you need to know
The federal No Surprises Act is a new law that took effect on January 1, 2022. The act seeks to protect consumers from surprise medical bills and requires increased transparency regarding healthcare costs. As a result of this expansive new law, there are many new regulations in effect following discretionary delayed enforcement by the Centers for Medicare & Medicaid services (CMS), while other parts of the law are awaiting rulemaking. These regulations will require new processes, workflows and maximized software tools by the majority of industry.
The intent of this article is not to provide legal advice, but to expose you to general content covered in the No Surprises Act with an emphasis on those elements that are most relevant to you now and for which software may be able to assist.
What we know about the No Surprises Act:
- Requires a good faith estimate (GFE) for uninsured/self-pay patients
- Requires a convening provider or facility (one who schedules the primary service) to provide an uninsured or self-pay patient with a GFE upon scheduling a visit or upon request by the patient.
- The GFE is required of all healthcare providers and is not specific to specialty, facility type or sites of service.
- The GFE must be provided to the patient within defined timelines based on how far in the future the appointment is being scheduled.
- The GFE must include specific data elements, such as codified services, delivery in the manner requested by the patient and represent the final cost to the patient (including any discounts, such as financial aid).
- The GFE must be kept on file by the convening healthcare organization for six years.
- While the law says all related co-provider/co-facility services must be included on the GFE given to the patient, CMS has indicated they will exercise enforcement discretion on this portion of the regulation until January 1, 2023.
The No Surprises Act also:
- Prohibits billing patients for more than their plan’s cost-sharing amount for emergency care, including certain services delivered by out-of-network providers at an in-network facility. It also requires private health plans to cover these out-of-network claims and apply in-network cost sharing.
- Requires a patient’s informed consent when services are provided by an out-of-network provider.
- Requires health plans to verify the accuracy of provider information included in the plan’s directory at least every 90 days and calls for providers to respond with updated information as necessary.
- Enables health plans and providers to negotiate privately over the amount to be paid for any surprise bill, and if they can’t agree, either party can ask for an Independent Dispute Resolution (IDR) process to decide the payment amount.
- Establishes a new final-offer arbitration process in the event an out-of-network provider and the health insurer can’t agree on a payment amount.
- Creates possible penalties for estimates in excess of a $400 difference.
No Surprises Act sections that are still awaiting regulations:
- Expanding the GFE requirements to insured patients.
- Requirement that the health plan create and send the patient an advanced explanation of benefits (AEOB) based on the good faith estimates submitted by the convening provider (and including co-provider/co-facility procedures) prior to any scheduled patient visit.
What Allscripts is doing
Allscripts is deeply involved in industry discussion to develop guidelines and recommendations for implementing various sections of the No Surprises Act. We have direct relationships with CMS and they have indicated that they know the GFE regulation for uninsured/self-pay patients is confusing. It offers insufficient time for the industry to adjust and some of the necessary infrastructure to support it is not yet in place. Informal indications from industry-listening sessions are that CMS doesn’t intend to enforce penalties specific to this regulation in the immediate future.
We actively contribute as leaders in several industry groups focused on these regulations:
- Workgroup for Electronic Data Interchange (WEDI): Recognized and trusted as a formal advisor to the Secretary of HHS and has convened multiple stakeholder groups into a task force that provides input and advises government regulators.
- Cooperative Exchange – The National Clearinghouse Association: For input on government regulations in the healthcare industry.
- Electronic Health Record Association: Regularly engages with CMS and other departments of HHS to address areas of concern about regulations affecting software developers and our clients.
- Partner with provider advocacy organizations (AMA, AAFP, MGMA, etc.) in related advocacy.
Look for webinars and blog posts on the for updates and information about how Allscripts products can help. All recorded webinars can be found in the Community Forum for Allscripts® Practice Management under the Allscripts PM Recorded Webinars topic.
Questions to consider
- How will I communicate expected services and costs with my co-providers and co-facilities?
- What backend processes and resources are needed to be able to provide diagnosis and procedure code(s) prior to the service being rendered?
- How will I satisfy estimate requirements when I don’t have enough information to produce or codify a GFE?
- How will I track my GFE against the final bill to ensure the estimated cost is not more than $400 different from the actual services rendered?
- How will I provide the GFE to the patient?
- Will the GFE processes and workflows I establish now to meet the uninsured/self-pay GFE requirements be able to be expanded to include the GFE requirements for insured patients when that regulation goes into effect?
- How will I change my appointment scheduling workflows, including appointment reminders, to accommodate the GFE?
The No Surprises Act legislation is massive and will impact many of your processes, workflows and tools. Here are a few good resources to get you started:
- Ensure you have a firm understanding of the No Surprises Act and what it can mean for your practice.
- Requirements Related to Surprise Billing; Part I
- Requirements Related to Surprise Billing; Part II
- Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing
- FAQ clarifying what’s in effect right now related to the GFE for uninsured/self-pay patients.
- Check payer and provider organization websites and bulletins to learn what solutions, updates and recommendations are available
- For questions about the provider requirements and provider enforcement email.
- Information about the Independent Dispute Resolution Process and others.
The Allscripts team remains committed to serving the healthcare industry to the best of our abilities.