Who doesn’t appreciate a delightful surprise? Unfortunately, surprises lose their charm when they involve unexpected medical bills. The joy quickly turns to concern when faced with unexpected expenses in healthcare.
What is a Surprise Medical Bill?
Surprise bills are also generally known as balance bills. A surprise bill lives up to its name by catching patients off guard with unexpected charges. These expenses arise when patients receive services from out-of-network providers, leaving them unaware of the additional costs involved.
According to recent studies, at least one out of five people received surprise bills after emergency care. It is no wonder that eight of ten respondents supported the passing of legislation such as the No Surprises Act (NSA).
Prior to the passing of the NSA, the federal government estimated that the act would affect about 10 million out-of-network surprise bills annually.
What is the No Surprises Act?
The No Surprises Act (NSA) entails new federal protection measures to protect patients from surprise medical bills and took effect on the first day of the year in 2022.
The NSA provides new billing protections for emergency and non-emergency care from both out-of- and in-network providers. Air ambulance services from out-of-network providers are also included.
So, in short, the NSA aims to protect consumers from surprise bills arising from medical care.
How does the No Surprises Act protect patients?
The No Surprises Act (NSA) protects the patient from surprise billing for emergency services. It achieves this through several key provisions:
- Limiting Patient Responsibility: The act establishes limits on what patients are required to pay for out-of-network emergency services and certain out-of-network services at in-network facilities. Patients are only responsible for their in-network cost-sharing amounts.
- Ending Surprise Billing: The act prohibits balance billing for emergency services and certain non-emergency services provided by out-of-network healthcare providers at in-network facilities. Instead, insurers and providers are required to resolve payment disputes through a structured dispute resolution (SDR) process.
- Transparency: The No Surprises Act mandates increased transparency in healthcare pricing. Healthcare providers are required to furnish patients with a good faith estimate of expected charges for services, enabling patients to make informed decisions about their care.
- Advance Explanation of Benefits (EOB): Patients are entitled to receive an Advance Explanation of Benefits that outlines the expected costs for scheduled procedures, helping them understand the financial implications before undergoing treatment.
- Independent Dispute Resolution (IDR): In cases where insurers and providers cannot agree on payment, an Independent Dispute Resolution process is implemented. An independent arbiter reviews the dispute and determines a fair resolution, protecting patients from being caught in the middle.
How do patients benefit from the No Surprises Act?
Let’s break it down in practical terms. Firstly, the NSA banned certain out-of-network charges on balance bills for certain services like anesthesiology and radiology when visiting an in-network facility.
Post-stabilization care is also considered to be emergency care until the physician decides it is safe to move a patient to an in-network facility. It is also required that the patient is given written notice and that the patient gives written consent before they can be moved to another facility.
Secondly, limitations are placed on out-of-network cost-sharing for most emergency and non-emergency services. Patients can’t be charged more than in-network cost-sharing.
Third, the NSA requires that the onus is on the provider or facility to give the patient easy-to-understand information about the billing protections, who to contact if protections were violated, and get consent from the patient before being balanced billed by an out-of-service provider.
The act also brings good news for patients who do not have health insurance and pay their medical expenses out of pocket. This act ensures that such patients are informed well in advance about the estimates of the expenses before they receive the medical care, and the patient is eligible to file a dispute within 120 days (about 4 months) of receiving the invoice if the bill is $400 more.
How does the NSA affect medical providers and facilities?
Let us now take a look at the other side of the coin. The act brings along certain guidelines that have to be followed by the providers and the facilities. The most prominent ones are:
- If providers charge patients more than the in-house cost-sharing amount for services covered by the NSA, providers could receive penalties of up to $10,000 per violation.
- Providers need to inquire about the patient’s insurance status and inform them if they are adequately covered. In emergencies, following the NSA, providers must now first inquire about the patient’s insurance plan and status and then submit the out-of-network bill directly to the health plan, unlike before when the bill was sent to the patient.
- Health plans must respond in 30 days to notify out-of-network providers of the applicable in-network cost-sharing amount. The medical plan will then inform the patient and explain the amount the patient owes the provider. Only after that can the out-of-network provider bill the patient.
- Although patients can waive their rights under the NSA to obtain medical service, providers are not allowed to ask patients to waive their rights for emergency and non-emergency care.
- The directories of the providers need to be up-to-date and verified.
- Verification of a provider’s office location, phone number, and digital contact information such as email and business hours are required every 90 days.
- Verification of who is doing what in which location is required every 90 days. In other words, businesses need to verify the physicians, their specialties, and where they are seeing patients.
- Online directories must be updated within 2 business days after any changes occur.
How can Neolytix assist with NSA compliance?
Neolytix has been helping healthcare organizations nationwide achieve their revenue, efficiency, and compliance objectives for almost 12 years.
As we explained in this article, the NSA impacts various processes within your practice, not just medical billing. With Neolytix’s as your partner, you can rest assured that you’ll stay on top of legislative changes at all times. Our expert teams are trained and constantly upskilled to understand and master new legislation that impacts healthcare providers nationwide.
To provide an example, the first place where the NSA has an impact on your practice and patient care during the scheduling of appointments. As we discussed earlier, the onus is now on the provider and facility to ensure that the patient is adequately covered and informed of any shortcomings.
Our virtual assistant (VA) teams and Patient Access Representatives are trained to ensure that within benefit verifications and prior authorizations, all boxes are ticked that the NSA demands.
Contact us today and schedule a demo to see how we can swing the legislative tides in your favor.