Ensuring Oncology Practice Compliance with the No Surprises Act

  • Product Marketing Manager, XiFin

The adverse impacts of surprise billing have garnered significant national attention, culminating in rare bi-partisan supported legislation that directly impacts community oncology practices. The No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021.

Surprise billing occurs when patients unknowingly receive either emergency or non-emergency care from an out-of-network provider. The law specifically targets balance billing, when providers attempt to recover the difference between in-network and out-of-network charges not covered by payors. While this practice is already prohibited by Medicare and Medicaid, the law is intended to extend similar protections at the federal level to patients insured through employer-sponsored and commercial health plans. The bulk of this legislation goes into effect January 1, 2022.

Prevalence of Surprise Billing in Oncology

In 2019 the American Cancer Society Cancer Action Network surveyed 1,392 recent cancer survivors and patients on this topic. 24% of the respondents indicated they had received a surprise medical bill. 62% of these surprise bills totaled $500 or more and 21% totaled at least $3,000.

The survey further explored the impacts of surprise billing among participants who received a surprise bill. Not surprisingly, a large majority (70% overall) was more likely to experience anxiety about “receiving another surprise bill and/or paying for my cancer treatments.” The effects of this experience were more acutely felt by lower income patients (those with less than $30,000 annual household income). For example, 53% of lower income respondents were “more likely to delay a recommended treatment because of worry about paying for it.”

No Surprises Act Rules

On July 1, the Biden-Harris Administration issued “Requirements Related to Surprise Billing; Part I,” an interim final rule, which is the first in a series of regulations stemming from this law. Per the official announcement, here are the key components:

  • Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.

  • Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.

  • Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.

  • Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

Patient Responsibility Estimator Key to Compliance

A real-time out-of-pocket estimation tool, as part of an advanced revenue cycle management solution, provides the right information to help ensure compliance. The XIFIN system produces this information by mapping current CPT-level costs, by payor, to real-time patient eligibility information. Out-of-pocket costs are then displayed as they would be in an explanation of benefits, along with copay, coinsurance, deductible, and remaining deductible information.

Providers have the flexibility to communicate the out-of-pocket responsibility while in consultation with the patient, or via self-service through the patient portal. Email and text notifications can also be utilized to notify patients when patient responsibility estimations are ready to be viewed.

Communicating patient out-of-pocket responsibility up front helps providers avoid potential civil monetary penalties up to $10,000 per violation. In addition, providers can avert the serious negative behavioral consequences identified by oncology patients who have faced unexpected treatment charges.

Want a closer look at XIFIN’s patient responsibility estimator, patient and physician portals, or other revenue cycle management capabilities?

Published by XiFin
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