The No Surprises Act

For providers and facilities who accept self pay patients, out of network providers performing services at in network facilities, this information is for you. As the “No Surprises Act” went into effect on January 1, 2022, it's important you understand what this means and what is all about.


The goal of the federal rule is to eliminate medical bills from out of network providers that perform services at in network facilities. (Because this would be a surprise bill to the patient).


AND protect self-pay patients from receiving bills for substantially higher amounts than they expected.Please read below about the No Surprises Act, as well as a few extra tips we want to make sure you’re aware of. In regards to the No Surprises Act, we are doing what we can to understand the act. Because of the newness of it, we are receiving conflicting information from attorneys. Based on our own research and consult, please read below.


This bill applies to:

  • All providers and facilities that provide care to self-pay patients

  • Out of network providers who deliver non-emergent care at an in-network facility (examples: An out of network provider performs work at a contracted hospital or ASC). In regards to anesthesia, pathology, radiology, assistant surgeons, we are not clear if it falls under an exception from the rule yet, or not.

In effect, the

  • Ban balance billing and out-of-network cost-sharing (like out-of-network co-insurance or copayments) for emergency and certain non-emergency services. In these situations, the patient’s cost for the service cannot be higher than if these services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.

  • Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility. Health care facilities include: hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers. (Some legal opinions differ on this subject and believe you should still obtain waiver and consent from patient and to err on side of caution).

  • For out of network providers at an in network facility, the act will ban certain other out-of-network charges and balance billing without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the patient. (examples in link)

  • For patients who don’t have insurance, these rules make sure patient will know how much their healthcare will cost before they get it, and might help them if they get a larger bill than expected. To comply, providers must post notification on their website and in office regarding self-pay patients’ right to receive good faith estimates prior to services being provided and provide formal good faith estimates.

  • For OON providers, allow providers and facilities dispute the rate paid by the payer, and initiate the IDR (independent Dispute Resolution) process.

  • Ban surprise billing for emergency services. Emergency services, even if they’re provided by an out-of-network provider, must be covered at an in-network rate without requiring prior authorization.

These requirements don’t apply to patients with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.


Please find links to additional resources below:

https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets

https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf


Action:

  • If you are an out of network provider who practices at an in network facility, we strongly encourage you to contact the facility to understand what they are adding to their paperwork regarding services and the “No Surprises Act.”

  • If you are an in network facility, please contact us or your management company, to understand their preparation for the No Surprises Act.”

  • If you are an anesthesia provider or company, providing out of network anesthesia services, please contact your management company to discuss preparation of good faith estimates.

  • If you perform any non-emergent services (professional or facility) that are for patients without insurance (Self Pay), you are required to prepare a good faith estimate and post a notice (please see this website for sample notices and good faith estimate forms).

Model Notices created by HHS to use: https://www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-10791


If you are not an active client of TTG Healthcare Advisors and would like assistance with the No Surprises Act, please feel free to contact us at: wendy@ttg-us.com.