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No Surprises Act Resource Center

The requirements to comply with the No Surprises Act are continually evolving so that's why we’ve created the No Surprises Act (NSA) Resource Center. We've included the latest NSA industry news, information, resources, and billing tools from industry experts. 

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No Surprises Act: Examining the Independent Dispute Resolution Process

The Final Rule implementing the No Surprises Act provides new guidance for the payor-provider independent dispute resolution (IDR) process.

No Surprises Act: 4 Key Steps to Providing Good Faith Estimates

The No Surprises Act protects patients from receiving a surprise medical bill by prohibiting balance billing and requiring providers to provide good faith estimates (GFE) of services.

Blog Post: Three Questions You Should Be Asking to Determine if the No Surprises Act Applies to You

How do the billing protections established under the No Surprises Act impact my group? This is what everyone is asking. It’s a very complex question that isn’t answered with a simple yes or no.

Blog Post: 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.

Blog Post: No Surprises Act: Your Top Questions Answered - Part 2

This blog is part two of a blog series focusing on answering the most common questions regarding the No Surprises Act. The No Surprises Act (NSA) — which provides patient protections by addressing surprise billing and banning balance billing — has many people wondering which parts of the Act apply to them and how to meet the requirements.

Blog Post: Preparing for the No Surprises Act: Learn How Your Billing Solution Can Help

Effective January 1, 2022, the No Surprises Act (NSA) established new federal protections against surprise medical bills and balance billing for services received from out-of-network providers.

Blog Post: How an Accurate Patient Out-of-Pocket Expense Estimator Helps Prevent Surprise Billing

There has been a lot written about surprise billing lately and the No Surprises Act, which includes surprise billing legislation, was signed into law the final week of 2020 and is slated to go into effect on Jan. 1, 2022.

FAQs

Does the No Surprises Act (NSA) impact me?

All healthcare providers and health care services, both emergency and non-emergency, are impacted by NSA. NSA does not apply to Medicare and Medicaid programs because patients must use a contracted provider under these programs. 

Can I bill the patient if insurance denies?

This is predicated on how the explanation of benefits (EOB) is returned. Providers should not bill the patient if the EOB returns with a contractual obligation denial code (CO). If the EOB returns with a patient responsibility denial code (PR), providers can bill that amount. While out-of-network (OON) payors should return the EOB with a PR denial code, sometimes providers who are unable to secure direct contracts are contracted under a third-party administrator with the payor and could receive a CO denial prohibiting billing.

When is patient consent required?

Providers are only required to obtain patient consent when balance-billing the patient the out-of-network rate, which is greater than the payor in-network allowable. Patient consent can only be obtained for non-emergency services. The consent exception does not apply to ancillary services.  

Can I obtain consent to balance bill ancillary services?

No, under the No Surprises Act, ancillary services, including pathology, laboratory, and radiology, which individuals typically have little control over, are always subject to balance billing prohibitions. 

What services should be included in a good faith estimate?

Good faith estimate (GFE) should include items or services reasonably expected to be furnished by both primary and co-provider. For example, when getting surgery, a good faith estimate should consist of the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. HHS has recognized 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.

If we don’t see the patient in person, how will patient tools help?

Patient eligibility and estimation tools, such as XIFIN’s patient estimation tool, can be embedded into the provider’s website so the patient or referring provider can check fees upfront. This tool is predicated on having the correct fee schedules loaded. 

How will NSA impact our billing process?

Initially, payors may not have the appropriate logic built into their system to provide the in-network patient responsibility rate on the EOB. Therefore, providers should update the billing process for out-of-network payors. Providers should work with payors proactively to establish an in-network rate, update fee schedules to ensure the in-network rate is billed for out-of-network charges, and review payment and/or denials from out-of-network payors.

Should we post a list of contracted providers?

Yes, providers may also want to post on their websites a list of insurance providers they are contracted with and encourage patients and referring providers to contact you directly to determine the status of a payor not listed on your website. Providers should also review payor websites to ensure they are listed appropriately on the payor website as an in-network provider. This will allow patients to quickly determine a provider’s contracted status with an insurance provider. 

Can fee schedules be assigned to a non-contracted group?

In the XIFIN RPM billing platform, fee schedules are assigned by Payor ID. Non-Contracted is a payor group that houses any Payor ID that is out-of-network, and each payor ID can have its own fee schedule.

What is the payor-provider dispute resolution process?

The NSA established an Independent Dispute Resolution(IDR) process to determine out-of-network payment between the provider and payor. The provider or plan has a 30-day window from the day the provider “receives an initial payment or notice of denial of payment” from the plan to initiate the open negotiation period. If the provider and plan cannot reach an agreement by the end of the 30-day open negotiation period, the plan or provider may initiate IDR. 

Are non-hospital services impacted?

NSA requirements include no balance billing for air ambulance services, out-of-network emergency services, and non-emergency services by nonparticipating providers at certain participating healthcare facilities, including hospital outpatient departments, critical access hospitals, and ambulatory surgical centers.  

How is the in-network rate identified?

Under the No Surprises Act, the out-of-network rate is determined by a hierarchy of factors, including state laws, an agreement between provider and payor, and an independent dispute resolution process. Providers, while out-of-network, may have a relationship with the payor and can determine the in-network rate by contacting the payor directly. If unable to obtain directly from the payor, providers can also calculate the average in-network rate by analyzing the rate from contracted payors. While this option is not as specific as working with the payor directly, it will provide a starting point. If a provider would like to dispute the payor denial or payment, they can initiate an independent dispute resolution process.

Who is responsible for obtaining patient consent?

For non-emergency services, when balance billing the patient for out-of-network services above the payor allowable, providers of the service are required to obtain patient consent.

When is a good faith estimate required?

A good faith estimate (GFE) is required when obtaining consent or providing services for the uninsured. GFE should include items or services reasonably expected to be furnished by both primary and co-provider.

How do I provide a good faith estimate?

Eligibility and patient responsibility tools, if available, are the most efficient way of providing good faith estimates. XIFIN RCM clients can embed the patient responsibility estimator into their website to provide direct access for the patient or referring provider.

What if the patient receives a Surprise Bill?

This may trigger the patient to call the insurance or healthcare provider. Having a customer service workflow process in place will help representatives handle patient phone calls.

Are state balance billing laws still applicable?

Prior to the national legislation, several states implemented legislation to address surprise billing. The No Surprises Act does not overrule state law. Some states may have additional requirements in addition to the national legislation.

How does NSA impact the in-network deductible?

Under NSA, any out-of-network healthcare cost will be applied to a patient’s in-network deductible and out-of-pocket maximum.

Is a signed requisition the same as patient consent?

There are statutory and regulatory requirements relating to the consent form required under the No Surprises Act. CMS has developed standard notice & consent forms regarding consumer consent on balance billing protections.

What is the patient-provider dispute resolution process?

NSA, established a patient-provider dispute resolution (PPDR) process, that can be initiated by the patient when actual billed charges are in excess of the good faith estimate by $400 or more. There is a $25 fee to use the dispute process and the process must be initiated within 120 calendar days from the date on the original bill.   

Who pays the payor-provider dispute resolution cost?

The party whose offer was not chosen during the independent dispute resolution (IDR) process pays the costs of IDR. The estimated associated cost relating to the IDR process is between $200 and $670, in addition to the $50 administrative.

How Can Your Billing Provider Help?

The following is a list of ways providers can leverage their billing system to assist with complying with the No Surprises Act.

Establish Fee Schedules by Payor

Within your billing system categorize payors as contracted vs non-contracted and associate the specific fee schedule by payor. For out-of-network payors your charge should equal the payor in-network allowable if defined upfront.

Determine In-Network Rate

Proactively contact any out-of-network payors to establish what the in-network rate is or work with the payor to define an agreed upon consistent approach such as % of fee schedule. This will allow providers to bill at agreed upon out-of-network rate from the start.

Educate Patient Services Representatives

Providers may not know they are providing service for an out-of-network payor until after the bill is sent and the patient calls customer service, therefore providers should have a Customer Service Workflow process in place to handle patient phone calls.

Utilize Patient Responsibility Estimator Tools

Patient estimation tools can assist the patient in understanding the out-of-pocket expense before the test is performed. Leveraging a patient out-of-pocket estimation tool, can proactively educate the patient and help them understand their out-of-pocket cost. 

Place Out-Of-Network Payors on Hold

If your billing system doesn’t have the functionality to establish individual fee schedules by payor, consider placing out-of-network payors on hold for manual review prior to sending a patient statement. This will provide an opportunity to review the Explanation Of Benefits (EOB) and ensure the patient is billed the corresponding in-network rate. This might be applicable for a hospital-based provider that is out-of-network with a specific payor that the hospital is contracted with.

Send Proactive Courtesy Letters to Patients

When applicable, consider sending a courtesy letter to patients, informing them that their claim should be processed by their insurance provider as in-network under the No Surprises Act. When utilized strategically, proactively educating patients prior to them receiving an explanation of benefits (EOB) from the payor or with their billing statement, can help alleviate patient confusion and patient phone calls. For instance, this might be utilized when a payor is denying claims for a hospital-based pathology group that is out-of-network when the hospital is in-network.

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Preparing for the No Surprises Act: Learn How Your Billing Solution Can Help


No Surprises Act: What You Need to Know and Do NOW!

The No Surprises Act (NSA) — which provides patient protections by addressing surprise billing and banning balance billing — has many people wondering which part of the Act applies to them and how to meet the requirements. Watch this webinar now to learn how you can leverage your billing solution to adhere to the No Surprises Act Requirements.

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Help Patients Avoid Surprise Bills With Patient Estimation Tools

Watch the video to learn how patient estimation tools can assist patients in understanding their out-of-pocket expense before a test is performed. Leveraging a patient out-of-pocket estimation tool, can proactively educate patients prior to receiving a bill and help them understand their out-of-pocket cost.

In the News

Stay up-to-date with the constant changes in the requirements to comply with the No Surprises Act and get the information you need.