No Surprises Act: Your Top Questions Answered - Part 1

The No Surprises Act (NSA), which went into effect on January 1, has many providers scrambling. 

The No Surprises Act provided protections for patients who unknowingly receive care from an out-of-network provider by addressing surprise billing and banning balance billing. Implementing the requirements of the No Surprises Act will require a new level of coordination between providers, payors, and patients that have not previously existed. As a result, there is a lot of confusion and questions surrounding the new legislation.

Listed below are answers to the most common questions related to the new legislation requirements around providing a good faith estimate (GFE) and obtaining patient consent. 

Is a good faith estimate of charges only required when obtaining consent or billing the uninsured or self-pay?  

Yes, a GFE is only required when obtaining consent to balance bill the patient and when providing services to uninsured or self-pay patients. A GFE should be provided before the service is provided to the patient. A GFE is required for all items or services scheduled at least 3 business days prior to the patient service date. CMS has developed specific forms which must be utilized when supplying a GFE.

Should a good faith estimate include all services including ancillary?

Yes, a GFE must include expected charges for all services that are reasonably expected to be provided in conjunction with primary items or services. For example, if having surgery at a surgery center, the GFE should include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation.

Are only providers with direct patient contact required to provide a good faith estimate?

No, all providers and facilities that provide services for the uninsured must provide a GFE. In situations where multiple providers (primary and co) are providing care, the primary provider is responsible for providing the GFE but that GFE should include items or services reasonably expected to be furnished by both primary and co provider.  

If a patient shows up for laboratory or imaging services without an appointment, do I have to provide a good faith estimate?

Yes, if an uninsured patient has a referral from a provider to get laboratory or imaging services, these services are ancillary services provided as part of the patient’s primary service. While the ancillary services are unscheduled the primary service was scheduled and therefore the GFE requirements are applicable. The GFE should have been provided to the patient by the referring provider prior to them receiving laboratory or imaging services and that GFE should include estimated charges for ancillary services. 

The good faith estimate requirement doesn’t go into effect until 2023, correct?

No, the good faith estimate under the NSA went into effect on January 1, 2022. However, HHS did recognize that this may take some coordination between the primary and co-providers and therefore, will exercise enforcement discretion on GFE that do not include all services until December 31, 2022.

Does a good faith estimate have to be equal to the actual billed charges? 

No, the legislation recognizes that it may be difficult to estimate the exact charge of a service, and that is why there is a $400 limit on when a patient can dispute the GFE. The patient can initiate a patient-provider dispute resolution process if the actual billed charges are in excess of the GFE by $400 or more. If a service is not provided in the GFE, that service is still subject to the patient-provider dispute resolution process. For example, if the GFE provided included $0.00 charges for pathology services, but as part of the treatment, the patient received a bill for pathology services, if the bill received was under $400 the patient cannot dispute the bill however if the bill is over $400 the patient can dispute the bill.

Do I have to obtain consent to balance bill the patient as an out-of-network provider?

Yes, for non-emergency services patient consent can be obtained to balance bill the patient as out-of-network an amount above the payor allowable. Patient consent must be obtained 72-hours prior to scheduled or 3-hours prior to unscheduled appointment and must include a good faith estimate of charges. To clarify, patient consent is not required to bill the patient as an out-of-network provider but can be obtained to balance bill the patient. CMS has provided specific forms which should be utilized when obtaining consent to balance bill the patient. 

Can pathology, laboratory, radiology, and other ancillary providers obtain consent to balance bill the patient?

No, for non-emergency services, certain providers can obtain patient consent to balance bill an amount above the payor allowable; however, under the NSA ancillary services, which individuals typically have little control over, are always subject to balance billing prohibitions. The NSA defines ancillary services as:

  • Related to emergency medicine, anesthesiology, pathology or radiology and neonatology,
  • Provided by assist surgeon, hospitalist and intensivists
  • Services which are part of diagnostic services, including radiology and laboratory services
  • Provided by an out-of-network provider when there is not an in-network provider who can provide the same service.

CMS has also issued a GFE Frequently Asked Questions and specific forms which are required when providing a GFE or obtaining consent.

Part Two of this blog series will focus on the most common questions related to balance billing and out-of-network billing. 

Additional XIFIN NSA Resources:

Download XIFIN’s Preparing for the No Surprises Act Step-by-Step Guide

Visit the XIFIN No Surprises Act Resource Center which includes FAQs, Complimentary Webinars, NSA industry news and resources from industry experts.

Read the January blog, Preparing for the No Surprises Act: Learn How Your Billing Solution Can Help

Published by XiFin
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