No Surprises Act Frequently Asked Questions

June 8, 2022

By: Tami Shaw, Client Manager

Federal Surprise Billing Law effective: Jan. 1, 2022

Overview:

The No Surprises Act (NSA) provides individuals and families covered by group and individual health plans protection against unexpected, high-priced medical bills for services delivered at in-network facilities by out-of-network (OON) providers.

Prior to implementation of the NSA, if a patient received care from an OON provider or an OON facility, even unknowingly, their health plan wasn’t obligated to cover the entire OON cost. That frequently left the patient with higher costs than would have been the case had they received care from an in-network provider or facility. Along with any OON cost-sharing the patient might owe, the OON provider—unless prohibited by state law—could also balance bill, or “surprise bill” the patient for the difference between the billed charge and the amount paid by the patient’s health plan.

When does it apply to labs?

When the patient’s location for the service originated in an in-network care setting during the visit, whether it was Emergent or Non-Emergent.

When does it apply for pathology groups?

When the patient’s location for the service originated in an in-network care setting during the visit, whether it was Emergent or Non-Emergent.

What are providers required to do for patient consent?

Provide a Good Faith Estimate to self-pay patients at least 72 hours before a scheduled service.

What if they have insurance, and are not self-pay?

Provider accepts the Insurance payment as payment in full and there is no balance billing. If the Insurance identifies any portion of the payment as patient responsibility per cost-sharing agreements defined in the plan between the insurance and the patient, then the amount identified as cost-sharing will be billed to the patient. Any amount outside of cost sharing will not be balance billed.

How do you dispute an OON payment?

  • Payers are required to make an initial payment or a denial of payment within 30 days of submission of a clean claim.
  • If the provider disagrees with the amount offered by the payer, both parties must engage in a 30-business-day open-negotiation period to reach an agreement regarding the total OON rate.

What if Payer and Provider do not reach an agreement?

Payment disputes are resolved by an independent arbitrator.

What if the state also has a balance billing law?

The NSA does not supersede state laws on balance billing if the existing law meets the baseline standards established by the federal law. Make sure you know the state laws for your location. Eighteen states have legislation prohibiting balance billing. CA, CO, CT, FL, GA, IL, ME, MD, MI, NH, NJ, NM, NY, OH, OR, TX, VA, WA

Is there anything else I can do to prepare?

  • Know which payers you are in network with.
  • Publicly post any applicable state balance bill laws, and the NSA on your website, and at your location(s). Be prepared to provide patients a one-page notice that includes the requirements for these laws.
  • Communicate with the hospitals you are doing business with and co-ordinate the creation and process of distributing a “Good Faith” letter to patients, for them to sign prior to services. Have a process for keeping these on file in medical records, and how you will access them when needed.

If you need assistance navigating the No Surprises Act, or developing the proper protocols to ensure compliance with this new regulation, don’t hesitate to contact us for a free consultation.

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