The No Surprises Act went into effect on January 1, 2022, despite litigation in multiple states. In Texas, a federal judge ruled in favor of the Texas Medical Association’s case regarding the appropriate out-of-network rate for arbitration. The Department of Health and Human Services (HHS) is moving forward with updating guidance on the arbitration process to meet the requirements of the court’s decision.
What Does It Mean for My Practice?
Overall, the No Surprises Act applies to out-of-network providers practicing in in-network facilities. Therefore, if your practice participates in the same health plans as your facility, the act does not apply to you. However, the second interim final rule included a provision that applies to all providers in all settings. A good faith estimate must be given to all self-pay patients.
Good Faith Estimate
The good faith estimate (GFE) must be given to all uninsured patients and self-pay patients (who are electing not to use insurance for services). The estimate must also be provided for all other providers involved in the procedure. So, the interventional cardiologist is also required to request an estimate from the facility and any other treating providers.
A notice of the availability of a good faith estimate should be posted both in the office and online in accessible formats for all patients. Uninsured patients should also be told verbally of the availability of the GFE, but the estimate must be provided in writing.
The GFE must be given to the patient no later than 3 business days after an appointment is scheduled if the appointment is more than 10 days out. If an appointment is scheduled between 3 and 10 days out, the GFE must be given no later than 1 business day after an appointment is scheduled. When requested without an appointment, the response should be no more than 3 business days after the request is made. If changes to the expected services occur, a new GFE must be provided no later than 1 business day before services are rendered.
The Written Document
The written GFE requires the following components and CMS has provided a template.
- Patient name and date of birth
- Clear description of service and date scheduled (if applicable)
- List of all items and services (including those to be provided by co-providers)
- CPT code, diagnosis code, and charge per item of service
- Name, NPI, and TIN of all service providers and the state where the services will be rendered
- List of items from other providers that will require separate scheduling
- Disclaimer that separate GFEs will be issued upon request for services listed in number 6, and that items in number 4 will be provided in those separate GFEs
- Disclaimer that there may be other services required that must be scheduled separately during treatment and are not included in the GFE
- Disclaimer that this is only an estimate and actual services, and charges may differ
- Disclaimer informing the patient of their rights to a patient-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process
- Disclaimer that GFE is not a contract and the patient is not required to obtain services from the provider
Patient-Provider Resolution Process
If billed charges exceed the GFE by $400, the patient may initiate a dispute resolution process. The patient has 120 days from receipt of the bill to initiate the dispute process with HHS.
Good Faith Estimate for Patients With Insurance
The Act also requires a good faith estimate to be provided for patients with insurance, but this provision has been deferred to future rulemaking. Additional information will be provided as it comes available.
Out of Network Provisions
The following provisions only apply to out-of-network providers performing services in participating facilities for patients with commercial healthcare plans:
- Cannot balance bill the patient for emergency services
- Cannot balance bill the patient for non-emergency services performed in a participating facility unless requirements for notice and consent are met
- Must disclose protections against balance billing
- Ensure continuity of care when provider ends contract with payor
These provisions do not apply to Medicare, Medicaid, Indian Health Services, Veterans Affairs, or Tricare beneficiaries.
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