While the No Suprises Act, which bars patients from receiving surprise bills directly from out-of-network providers in most instances, officially went into effect Jan. 1, 2022, the law is still facing a number of legal challenges from provider groups unhappy with the payment dispute resolution process, to say nothing of the uncertainty surrounding its implementation.
The act primarily prevents patients from being billed in emergency scenarios or non-emergent situations where the patient did not have reasonable access to an in-network provider. In such situations, patients will be responsible only for their in-network cost sharing responsibility. Payers and providers would then negotiate the remainder of the bill. However, the dispute resolution process for doing so remains a point of contention, with provider groups saying the process gives insurers too much power to set rates and further restrict their networks.
With that in mind, labs and pathology groups should still do everything in their power to come into compliance with the new regulation. Below are some initial steps being recommended by the Vachette team for both providers and their billers:
- Upload all payer contracts that the Pathology group has and keep consistent track through contract management reporting of the paid allowable.
- Have a process of tracking the “out-of-network” denials and for manual review.
- Ensure that the physicians are compensated fairly based on the payer’s allowable.
- Be aware if the insurance companies are lowering the allowable paid to the physician — the payment may be rejected if it is below the set allowable.
- Make sure the hospitals have The No Surprises Act or applicable state balance bill law publicly posted and on their website. Also be able to provide to patients a one-page notice that includes the requirements for this new law
- Physicians need to communicate with their hospital on putting together the “good faith” letter for patients to sign before any procedures.
- “Good Faith” Letter: CMS has released a model of this letter that satisfies what is expected to be considered “good faith”.
- This document is to be a standalone document and can be either electronic or paper. It must be received at least 72 hours before a procedure is performed.
- This “good faith” estimate that is included on the consent form must now be included on the patient’s medical record.
Remember, these are just initial recommended steps intended to show your group is making a good faith effort to comply with this new law. If you have questions about next steps, or are seeking feedback on when this law applies to your billing practices, don’t hesitate to reach out to us directly at 517-486-4262.